Provider Demographics
NPI:1053088005
Name:WAGNER, BLAIR
Entity Type:Individual
Prefix:
First Name:BLAIR
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 MAGNOLIA ST # B
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70460-8821
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1501 MAGNOLIA ST # B
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70460-8821
Practice Address - Country:US
Practice Address - Phone:504-400-3896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA009605995343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)