Provider Demographics
NPI:1003227968
Name:WAGNER, LAUREN (DO)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 HEMLOCK ST # 117
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2102
Mailing Address - Country:US
Mailing Address - Phone:478-633-1000
Mailing Address - Fax:
Practice Address - Street 1:777 HEMLOCK ST
Practice Address - Street 2:MSC 42
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2102
Practice Address - Country:US
Practice Address - Phone:478-633-7600
Practice Address - Fax:478-633-7354
Is Sole Proprietor?:No
Enumeration Date:2014-05-14
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA77978208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics