Provider Demographics
NPI:1902852544
Name:WAGSTROM, LOIS (MD)
Entity Type:Individual
Prefix:DR
First Name:LOIS
Middle Name:
Last Name:WAGSTROM
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 1:310 23RD AVE N
Mailing Address - Street 2:STE. 100
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1525
Mailing Address - Country:US
Mailing Address - Phone:615-329-1822
Mailing Address - Fax:
Practice Address - Street 1:310 23RD AVE N
Practice Address - Street 2:STE. 100
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1525
Practice Address - Country:US
Practice Address - Phone:615-329-1822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0212522086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3058358Medicare PIN
TN30583581Medicare PIN