Organization
LAURA WAGNER, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LAURA ELLA WAGNER M.D. (PRESIDENT)
(636) 926-8554
Entity
Organization
Contact information
Practice address
6 JUNGERMANN CIR, SUITE 211, SAINT PETERS, MO 63376-1621
(636) 926-7938
(636) 926-2286
Mailing address
PO BOX 790379, SAINT LOUIS, MO 63179-0379
(636) 926-7938
(636) 926-2286
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
R8N01
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00004839
MEDICARE PTAN #
MO
01
—
1669445060
TYPE 1 NPI
MO
01
—
18374
BCBSMO PROVIDER#
MO
01
—
211386
HEALTHLINK ID#
MO
01
—
39228V39228
GHP PROVIDER #
MO
01
—
4420124
AETNA PROVIDER #
MO
Enumeration date
08/19/2008
Last updated
08/19/2008
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