Provider Demographics
NPI:1871720482
Name:WAGNER, BETH ELLEN (DO)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:ELLEN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:ATT: CVMC FINANCE DEPT
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-0547
Mailing Address - Country:US
Mailing Address - Phone:802-225-1743
Mailing Address - Fax:802-225-1745
Practice Address - Street 1:130 FISHER RD
Practice Address - Street 2:HOSPITALIST PROGRAM
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-9516
Practice Address - Country:US
Practice Address - Phone:802-225-1743
Practice Address - Fax:802-225-1745
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AK5247207Q00000X, 390200000X
VT032.0095970207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1022074Medicaid
AKMD0914Medicaid
VTY400100808Medicare PIN