Provider Demographics
NPI:1457671455
Name:WAGSTROM, EMILY ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:EMILY
Middle Name:ANNE
Last Name:WAGSTROM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:DEPARTMENT OF ORTHOPAEDIC SURGERY
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:DEPARTMENT OF ORTHOPAEDIC SURGERY
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1007
Practice Address - Country:US
Practice Address - Phone:319-353-6604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-8859207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery