Provider Demographics
NPI:1295147908
Name:WAGNER, RUTH ANNE (MD)
Entity type:Individual
Prefix:DR
First Name:RUTH
Middle Name:ANNE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RUTH
Other - Middle Name:ANNE
Other - Last Name:BURLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:98 MASONIC DR STE 101
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17022-2569
Mailing Address - Country:US
Mailing Address - Phone:717-361-8449
Mailing Address - Fax:
Practice Address - Street 1:98 MASONIC DR STE 101
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:PA
Practice Address - Zip Code:17022-2569
Practice Address - Country:US
Practice Address - Phone:717-361-8449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-29
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD461020207Q00000X, 207QH0002X
PAMT206016390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program