Provider Demographics
NPI:1518949650
Name:WEGNER, MATTHEW BRENT (APRN, FNP-C)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:BRENT
Last Name:WEGNER
Suffix:
Gender:M
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:325 EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71292-6458
Mailing Address - Country:US
Mailing Address - Phone:318-512-4443
Mailing Address - Fax:318-398-9986
Practice Address - Street 1:101 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-8309
Practice Address - Country:US
Practice Address - Phone:318-387-5244
Practice Address - Fax:318-398-9986
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAAP04788363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1787132Medicaid
LA4H651D113Medicare PIN