Provider Demographics
NPI:1568715712
Name:WAGONER, TRACI
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:WAGONER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 ZUMBEHL RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-1131
Mailing Address - Country:US
Mailing Address - Phone:636-443-4202
Mailing Address - Fax:636-277-7386
Practice Address - Street 1:2424 ZUMBEHL RD
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-1131
Practice Address - Country:US
Practice Address - Phone:636-443-4202
Practice Address - Fax:636-277-7386
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012033129363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily