Provider Demographics
NPI:1700046190
Name:WANNEBO, ELIZABETH LE (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:LE
Last Name:WANNEBO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:NGOC
Other - Last Name:LE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1011 BOYDS SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:GETTYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17325-8580
Mailing Address - Country:US
Mailing Address - Phone:859-327-0671
Mailing Address - Fax:
Practice Address - Street 1:1011 BOYDS SCHOOL RD
Practice Address - Street 2:
Practice Address - City:GETTYSBURG
Practice Address - State:PA
Practice Address - Zip Code:17325-8580
Practice Address - Country:US
Practice Address - Phone:859-327-0671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD434557207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA211210OtherJOHNS HOPKINS
MD018317200Medicaid
PA2056156OtherHIGHMARK BLUE SHIELD
PA102170568Medicaid
PA120275OtherGEISINGER HEALTH PLAN
MD935776OtherCAREFIRST MD BCBS
PA9928179OtherAETNA
PA127572Medicare PIN