Provider Demographics
NPI:1669445060
Name:WAGNER, LAURA ELLA (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ELLA
Last Name:WAGNER
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 1:14377 WOODLAKE DR
Mailing Address - Street 2:SUITE 111
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5735
Mailing Address - Country:US
Mailing Address - Phone:314-434-1111
Mailing Address - Fax:314-434-1112
Practice Address - Street 1:14377 WOODLAKE DR
Practice Address - Street 2:SUITE 111
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5735
Practice Address - Country:US
Practice Address - Phone:314-434-1111
Practice Address - Fax:314-434-1112
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8N01174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO18374OtherBCBSMO PROVIDER #
MO431895147OtherTAX ID#
MO211386OtherHEALTHLINK ID#
MO39228V39228OtherGHP PROVIDER #
MO4420124OtherAETNA PROVIDER #
MO211386OtherHEALTHLINK ID#
MO000094839Medicare ID - Type Unspecified