Provider Demographics
NPI:1154371664
Name:WAGNER, DEBORAH E (PA-C)
Entity type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:E
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:DEBORAH
Other - Middle Name:E
Other - Last Name:WEBMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1001 CHESTERFIELD PKWY E
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2041
Mailing Address - Country:US
Mailing Address - Phone:314-878-3839
Mailing Address - Fax:314-878-6575
Practice Address - Street 1:1001 CHESTERFIELD PKWY E
Practice Address - Street 2:SUITE 101
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-2041
Practice Address - Country:US
Practice Address - Phone:314-878-3839
Practice Address - Fax:314-878-6575
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004000667363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00169010OtherRAILROAD MEDICARE
MOQ21499Medicare UPIN
MO000097114Medicare ID - Type Unspecified