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General NPI Number Information
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NPI Number | 1194956276
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Entity Type | Organization
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Legal Business Name | LAURA WAGNER INC
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Dates
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Enumeration Date | 08/06/2009
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Last Update Date | 11/28/2012
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Provider Practice Location Address
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Address Line | 14377 WOODLAKE DR SUITE 111
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City | TOWN AND COUNTRY
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State | MO
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Zip | 63017-5735
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Country | US
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Telephone | 314-434-1111
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Fax | 314-434-1127
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Provider Business Mailing Address
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Address Line | PO BOX 790379
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City | SAINT LOUIS
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State | MO
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Zip | 63179-0379
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Country | US
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Telephone | 314-434-1111
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Fax | 314-434-1112
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LAURA WAGNER
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Credential | M.D.
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Telephone | 314-434-1111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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