Healthcare Provider Details

I. General information

NPI: 1295147908
Provider Name (Legal Business Name): RUTH ANNE WAGNER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: RUTH ANNE BURLEY

II. Dates (important events)

Enumeration Date: 05/29/2014
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 MASONIC DR STE 101
ELIZABETHTOWN PA
17022-2569
US

IV. Provider business mailing address

98 MASONIC DR STE 101
ELIZABETHTOWN PA
17022-2569
US

V. Phone/Fax

Practice location:
  • Phone: 717-361-8449
  • Fax:
Mailing address:
  • Phone: 717-361-8449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD461020
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT206016
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberMD461020
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: