Provider Demographics
NPI:1205440138
Name:WAGNER, BETH ANN (CRNP)
Entity type:Individual
Prefix:MRS
First Name:BETH
Middle Name:ANN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2608 KEISER BLVD
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-3333
Mailing Address - Country:US
Mailing Address - Phone:610-685-5864
Mailing Address - Fax:
Practice Address - Street 1:2608 KEISER BLVD
Practice Address - Street 2:
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-3333
Practice Address - Country:US
Practice Address - Phone:610-685-5864
Practice Address - Fax:610-929-1528
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP023015363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner