Individual
JESSICA G WAGEMAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
6500 EXCELSIOR BLVD, ST LOUIS PARK, MN 55426-4702
(952) 993-3246
(952) 993-3010
Mailing address
6500 EXCELSIOR BLVD, ST LOUIS PARK, MN 55426-4702
(952) 993-3246
(952) 993-3010
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
002025
IA
363A00000X
Physician Assistant
Primary
10903
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
002025
PA LICENSE
IA
01
—
10903
MINNESOTA LICENSE
MN
Enumeration date
09/16/2009
Last updated
12/10/2018
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