Provider Demographics
NPI:1063480879
Name:WAGNER, LAURIE A (CRNA)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:A
Last Name:WAGNER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30585
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87190-0585
Mailing Address - Country:US
Mailing Address - Phone:505-243-7729
Mailing Address - Fax:505-243-4804
Practice Address - Street 1:4401 MASTHEAD ST NE
Practice Address - Street 2:SUITE 120
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4493
Practice Address - Country:US
Practice Address - Phone:505-243-7729
Practice Address - Fax:505-243-4804
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR32370367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMQ6459Medicaid
NM343414200Medicare PIN