Provider Demographics
NPI:1851074959
Name:WAGNER, EMMA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10345 WATSON RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-1105
Mailing Address - Country:US
Mailing Address - Phone:314-965-6033
Mailing Address - Fax:
Practice Address - Street 1:10345 WATSON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1105
Practice Address - Country:US
Practice Address - Phone:314-965-6033
Practice Address - Fax:314-965-6067
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20232032275363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily