Basic Information
| Provider Information | |||||||||
| NPI: | 1205440138 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | BETH | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2608 KEISER BLVD | ||||||||
| Address2: | |||||||||
| City: | WYOMISSING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 196103333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106855864 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2608 KEISER BLVD | ||||||||
| Address2: | |||||||||
| City: | WYOMISSING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 196103333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106855864 | ||||||||
| FaxNumber: | 6109291528 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2020 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | SP023015 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.