Laura Wagner

Primary specialty

Medical Physician AssistantTaxonomy code 363AM0700X

License

PA5304 Issued in TN

Practice address

105 W Stone Dr Ste 1F
Kingsport, TN 37660-3365

Phone

(423) 230-2420

NPI assigned

Dec 8, 2022

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Laura Baker Former name

Medicare fee-for-service enrollment

Enrolled in TN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Lincoln Memorial University Medical Department, 2022

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Holston Medical Group PCGroup PAC ID 8224935754, 239 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Holston Medical Group PC

  • Family Medicine Physician
  • Kingsport, TN
  • NPI 1831110667
  Medicare reassignment Care Compare group NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1670457600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1718928000000",
    "number": "1013628262",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 9",
            "city": "KINGSPORT",
            "state": "TN",
            "postal_code": "376620009",
            "telephone_number": "423-857-2066"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "105 W STONE DR STE 1F",
            "city": "KINGSPORT",
            "state": "TN",
            "postal_code": "376603365",
            "telephone_number": "423-230-2420"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "LAURA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2022-12-08",
        "last_updated": "2024-06-21",
        "certification_date": "2024-06-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "TN",
            "license": "PA5304",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "LAURA",
            "last_name": "BAKER",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Bryan Justice Vrailas
• Duc Q Vu, M.D.
• Angela Ree Wackowski, PHARMD
• Beverly Jane Waddell, ANP, GCNS
• Benjamin Kent Wagner, LPC-MHSP
• Megan Elizabeth Wagner, FNP-C
• Wal-Mart Stores East LP
• Wal-Mart Stores East LP
• Wal-Mart Stores East, LP
• Wal-Mart Stores East, LP

• Medical Physician Assistant in Kingsport, TN
• Providers in Kingsport, TN by specialty
• Medical Physician Assistant in Tennessee

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 21, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.