Provider Demographics
NPI:1518216332
Name:WAGNER, LAURA BETH (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:BETH
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 1:14 DEERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-2817
Mailing Address - Country:US
Mailing Address - Phone:732-574-2481
Mailing Address - Fax:
Practice Address - Street 1:14 DEERWOOD DR
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-2817
Practice Address - Country:US
Practice Address - Phone:732-574-2481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015966363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant