Provider Demographics
NPI:1487801635
Name:LAURA WAGNER, INC
Entity type:Organization
Organization Name:LAURA WAGNER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:ELLA
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-926-8554
Mailing Address - Street 1:PO BOX 790379
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63179-0379
Mailing Address - Country:US
Mailing Address - Phone:636-926-7938
Mailing Address - Fax:636-926-2286
Practice Address - Street 1:6 JUNGERMANN CIR
Practice Address - Street 2:SUITE 211
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1621
Practice Address - Country:US
Practice Address - Phone:636-926-7938
Practice Address - Fax:636-926-2286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8N01174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO00004839OtherMEDICARE PTAN #
MO211386OtherHEALTHLINK ID#
MO4420124OtherAETNA PROVIDER #
MO39228V39228OtherGHP PROVIDER #
MO1669445060OtherTYPE 1 NPI
MO18374OtherBCBSMO PROVIDER#
MO00004839OtherMEDICARE PTAN #