Individual
LACY ROSE WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
6051 W EMERALD ST, BOISE, ID 83704-8969
(208) 302-5150
(208) 302-5155
Mailing address
3340 E GOLDSTONE DR, MERIDIAN, ID 83642-1026
(208) 302-9342
(208) 367-5180
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA-2169
ID
363A00000X
Physician Assistant
—
—
Other
Enumeration date
09/21/2021
Last updated
01/26/2022
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