Individual
DR. LAURA ELLA WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
14377 WOODLAKE DR, SUITE 111, CHESTERFIELD, MO 63017-5735
(314) 434-1111
(314) 434-1112
Mailing address
14377 WOODLAKE DR, SUITE 111, CHESTERFIELD, MO 63017-5735
(314) 434-1111
(314) 434-1112
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
R8N01
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
18374
BCBSMO PROVIDER #
MO
01
—
211386
HEALTHLINK ID#
MO
01
—
39228V39228
GHP PROVIDER #
MO
01
—
431895147
TAX ID#
MO
01
—
4420124
AETNA PROVIDER #
MO
Enumeration date
02/08/2006
Last updated
05/24/2012
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