Provider Demographics
NPI:1194956276
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:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-434-1111
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:314-434-1111
Mailing Address - Fax:314-434-1112
Practice Address - Street 1:14377 WOODLAKE DR
Practice Address - Street 2:SUITE 111
Practice Address - City:TOWN AND COUNTRY
Practice Address - State:MO
Practice Address - Zip Code:63017-5735
Practice Address - Country:US
Practice Address - Phone:314-434-1111
Practice Address - Fax:314-434-1127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-06
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000094839OtherPTAN
MO000094839OtherPTAN