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ETHAN SCOTT WAGNER MD
NPI 1174324420
Student in an Organized Health Care Education/Training Program in Boston, MA

Active since March 22, 2025PECOS Enrolled

NPPES record last updated: March 22, 2025. Verified against the NPPES registry weekly; last sync: July 26, 2026.

About Ethan Scott Wagner Md NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

ETHAN SCOTT WAGNER MD (NPI 1174324420) is an individual student in an organized health care education/training program in Boston, Massachusetts, licensed in Massachusetts (PENDING) and active in the NPI registry since March 2025. He is enrolled in Medicare PECOS.

NPPES Registry Identity

NPI1174324420
Entity TypeIndividualMale
Primary Taxonomy390200000X
Provider Legal NameETHAN SCOTT WAGNERCredential: MD
Location Address55 FRUIT STBoston, MA 02114-2621
Mailing Address55 Fruit StBoston, MA 02114-2621 · (617) 726-2000
Phone(617) 726-2000
Sole ProprietorYes
Enumeration DateMarch 22, 2025
NPPES CertifiedMarch 22, 2025
✔ NPI 1174324420 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyStudent in an Organized Health Care Education/Training ProgramStudent, Health Care
Taxonomy Code390200000X
License✔ Licensed in MA · PENDING
Definition
An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care.
55 FRUIT ST, Boston, MA 02114
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Medicare Participation & PECOS CMS

Medicare enrollment, assignment, and ordering and referring status from the CMS PECOS system.

Medicare Enrollment Status

✔

Enrolled in Medicare (PECOS)

Ethan Scott Wagner Md is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS).

Eligible to Order & Refer✔ Part B Labs & Imaging✔ Durable Medical Equipment✔ Home Health Agency✔ Power Mobility DevicesPer the CMS Ordering and Referring file. Eligibility means Medicare pays claims that this provider orders or refers for these categories.

Other Providers at the Same Location NPPES 20

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

STUTI GIRISH SHROFF MD, MBBS
Pathology (Anatomic Pathology)
55 FRUIT ST
BOSTON, MA 02114
Suffolk County (617) 726-2971
NANCY WANG M.D.
Internal Medicine (Hematology & Oncology)
55 FRUIT ST
BOSTON, MA 02114
Suffolk County (017) 724-4000
DR. DUSAN HANIDZIAR M.D., PH.D.
Anesthesiology
55 FRUIT ST, GRAY-BIGELOW 444
BOSTON, MA 02114
Suffolk County (617) 726-3030
JOHN JOSEPH DANKO DO
Physical Medicine & Rehabilitation
55 FRUIT ST
BOSTON, MA 02114
Suffolk County (617) 726-2000
DR. MICHAEL ANDREW LOBRITZ M.D, PH.D.
Internal Medicine (Infectious Disease)
55 FRUIT ST, DIVISION OF INFECTIOUS DISEASE, GRJ-504
BOSTON, MA 02114
Suffolk County (617) 724-9248
MS. KELLY ELISHA TRECARTIN NP
Nurse Practitioner (Acute Care)
55 FRUIT ST, BIGALOW 852 F
BOSTON, MA 02114
Suffolk County (617) 726-7400
JAMIE MARIE ALLEN NP
Nurse Practitioner
55 FRUIT ST
BOSTON, MA 02114
Suffolk County (617) 724-4410
DR. DHAVAL SANJEEV KOLTE M.B.B.S., PH.D.
Internal Medicine (Cardiovascular Disease)
55 FRUIT ST
BOSTON, MA 02114
Suffolk County (617) 643-3238

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Ethan Wagner's NPI number?

The NPI number for Ethan Wagner is 1174324420. It was assigned to this individual provider in the NPPES registry on March 22, 2025.

Where is Ethan Wagner located?

Ethan Wagner practices at 55 Fruit St, Boston, MA 02114. The listed phone number is (617) 726-2000.

What is Ethan Wagner's specialty?

The primary specialty registered for this NPI is Student in an Organized Health Care Education/Training Program with taxonomy code 390200000X.

Is Ethan Wagner enrolled in Medicare?

Yes. Ethan Wagner is registered in the Medicare PECOS enrollment system.

When was this NPI record last updated?

The NPPES record for Ethan Wagner was last updated on March 22, 2025. NPI Profile syncs with the weekly NPPES data releases published by CMS.