Basic Information
| Provider Information | |||||||||
| NPI: | 1154371664 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEBMAN | ||||||||
| OtherFirstName: | DEBORAH | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1001 CHESTERFIELD PKWY E | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630172041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148783839 | ||||||||
| FaxNumber: | 3148786575 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 CHESTERFIELD PKWY E | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630172041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148783839 | ||||||||
| FaxNumber: | 3148786575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 08/31/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2004000667 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P00169010 | 01 | MO | RAILROAD MEDICARE | OTHER |