Provider Demographics
NPI:1386268795
Name:WAGNER, LAUREN C (PA-C)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:C
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:C
Other - Last Name:O'KEEFE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3912 TRINDLE RD
Mailing Address - Street 2:
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011-4246
Mailing Address - Country:US
Mailing Address - Phone:717-761-8740
Mailing Address - Fax:717-761-8792
Practice Address - Street 1:3912 TRINDLE RD
Practice Address - Street 2:
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-4246
Practice Address - Country:US
Practice Address - Phone:717-761-8740
Practice Address - Fax:717-761-8792
Is Sole Proprietor?:No
Enumeration Date:2020-06-01
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061541363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103807191Medicaid