MEDICARE: BETHANY DOLORES WAGLER LM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	176B00000X	Midwife	99074	TX

General Provider Information

NPI Number	:	1104159474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETHANY DOLORES WAGLER LM

Provider Business Mailing Address
First Line	:	9313 W LONGVIEW RD
Second Line	:
City	:	PARTRIDGE
State	:	KS
Zip	:	67566-9030
Country	:	US
Telephone Number	:	620-960-6072
Fax Number	:

Provider Business Practice Location Address
First Line	:	9313 W LONGVIEW RD
Second Line	:
City	:	PARTRIDGE
State	:	KS
Zip	:	67566-9030
Country	:	US
Telephone Number	:	620-960-6072
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/17/2009
Last Update Date	:	09/17/2009

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