Provider Demographics
NPI:1417683277
Name:WAGNER, SOPHIA COLLETTE
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:COLLETTE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 HOUMA BLVD
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-2970
Mailing Address - Country:US
Mailing Address - Phone:504-503-6781
Mailing Address - Fax:
Practice Address - Street 1:4320 HOUMA BLVD FL 5
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-2961
Practice Address - Country:US
Practice Address - Phone:504-503-6565
Practice Address - Fax:504-456-8053
Is Sole Proprietor?:No
Enumeration Date:2022-07-25
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA226793363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily