Provider Demographics
NPI:1821435314
Name:WAGSTAFF, LAUREN J (DO)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:J
Last Name:WAGSTAFF
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 W HAMLET AVE
Mailing Address - Street 2:STE 5
Mailing Address - City:HAMLET
Mailing Address - State:NC
Mailing Address - Zip Code:28345-4565
Mailing Address - Country:US
Mailing Address - Phone:910-582-5166
Mailing Address - Fax:
Practice Address - Street 1:1021 W HAMLET AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:HAMLET
Practice Address - State:NC
Practice Address - Zip Code:28345-4564
Practice Address - Country:US
Practice Address - Phone:910-582-5166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-24
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-01057207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine