Provider Demographics
NPI:1336104074
Name:WAGNER, BETH A (CRNP)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:A
Last Name:WAGNER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:
Other - Last Name:TURNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT STREET
Mailing Address - Street 2:SUITE 301
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4405
Mailing Address - Country:US
Mailing Address - Phone:215-955-7190
Mailing Address - Fax:215-923-9186
Practice Address - Street 1:833 CHESTNUT STREET
Practice Address - Street 2:SUITE 301
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4405
Practice Address - Country:US
Practice Address - Phone:215-955-7190
Practice Address - Fax:215-923-9186
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP008597363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health