Provider Demographics
NPI:1922110048
Name:WAGENKNECHT, ALISON RENE (MD)
Entity type:Individual
Prefix:DR
First Name:ALISON
Middle Name:RENE
Last Name:WAGENKNECHT
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 1:1835 W. CTY RD C
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:763-785-4500
Mailing Address - Fax:
Practice Address - Street 1:1835 W. CTY RD C
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113
Practice Address - Country:US
Practice Address - Phone:763-785-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37558207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6603819OtherMEDICA URGENT CARE
MN0100730OtherMEDICA
MN5882147OtherAETNA INS
MNHP19980OtherHEALTHPARTNERS
MN09F08WAOtherBCBS OF MN
MN106664OtherUCARE MN
MN1011665OtherPREFERRED ONE
MN577314800Medicaid
MN88302OtherAMERICA'S PPO
MN080102136Medicare ID - Type UnspecifiedRR MEDICARE
MN080004600Medicare ID - Type UnspecifiedWPS MEDICARE
MNHP19980OtherHEALTHPARTNERS