Provider Demographics
NPI:1962621649
Name:TROTTER, WANDA D (NP)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:D
Last Name:TROTTER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:WANDA
Other - Middle Name:
Other - Last Name:CLAXTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1717 BIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63106-3454
Mailing Address - Country:US
Mailing Address - Phone:314-814-8515
Mailing Address - Fax:314-814-8542
Practice Address - Street 1:1717 BIDDLE ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106-3454
Practice Address - Country:US
Practice Address - Phone:314-814-8515
Practice Address - Fax:314-814-8542
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO052260363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427757711Medicaid