Provider Demographics
NPI:1093576506
Name:WAGNER, EMILY ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:ANN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11303 PRESWICK BLVD
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-4410
Mailing Address - Country:US
Mailing Address - Phone:507-581-4722
Mailing Address - Fax:
Practice Address - Street 1:1925 WOODWINDS DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4445
Practice Address - Country:US
Practice Address - Phone:507-581-4722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant