Provider Demographics
NPI:1699417030
Name:WAGNER, RUTH LARA (BS)
Entity Type:Individual
Prefix:
First Name:RUTH LARA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3411 MONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79903-4330
Mailing Address - Country:US
Mailing Address - Phone:915-777-7199
Mailing Address - Fax:915-307-3149
Practice Address - Street 1:3411 MONTANA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79903-4330
Practice Address - Country:US
Practice Address - Phone:915-777-7199
Practice Address - Fax:915-307-3149
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health