Provider Demographics
NPI:1457388035
Name:WAGUESPACK, ALEXIS M (MD)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:M
Last Name:WAGUESPACK
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 1:3939 HOUMA BLVD STE 18
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-2921
Mailing Address - Country:US
Mailing Address - Phone:504-392-7123
Mailing Address - Fax:504-392-7823
Practice Address - Street 1:3939 HOUMA BLVD STE 18
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-2921
Practice Address - Country:US
Practice Address - Phone:504-392-7123
Practice Address - Fax:504-392-7823
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.09377R207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1955884Medicaid
LAF45378Medicare UPIN
LA5R397CW25Medicare ID - Type Unspecified
LA1955884Medicaid