Provider Demographics
NPI:1740660117
Name:WAGNER, BETH ELLEN (MD)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:ELLEN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:ELLEN
Other - Last Name:BOURNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:800 WEST AVE S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-8806
Practice Address - Country:US
Practice Address - Phone:608-785-0940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN61229207V00000X
WI71316207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology