Provider Demographics
NPI:1215341920
Name:WILE, LAUREN WAGNER (PA-C)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:WAGNER
Last Name:WILE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:M
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:13800 W NORTH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4977
Mailing Address - Country:US
Mailing Address - Phone:262-754-4488
Mailing Address - Fax:262-754-4940
Practice Address - Street 1:1111 DELAFIELD ST
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3417
Practice Address - Country:US
Practice Address - Phone:262-754-4488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3319363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1215341920Medicaid