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General NPI Number Information
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NPI Number | 1487801635
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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 | 08/19/2008
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Last Update Date | 08/19/2008
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Provider Practice Location Address
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Address Line | 6 JUNGERMANN CIR SUITE 211
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City | SAINT PETERS
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State | MO
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Zip | 63376-1621
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Country | US
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Telephone | 636-926-7938
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Fax | 636-926-2286
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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 | 636-926-7938
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Fax | 636-926-2286
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Authorized Official
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Title or Position | PRESIDENT
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Name | LAURA ELLA WAGNER
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Credential | M.D.
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Telephone | 636-926-8554
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | R8N01
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License Number State | MO
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