Healthcare Provider Details

I. General information

NPI: 1699091264
Provider Name (Legal Business Name): KENDALL DARREN WAGNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2010
Last Update Date: 09/13/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S UNIVERSITY AVE STE 702
LITTLE ROCK AR
72205-5309
US

IV. Provider business mailing address

46 MIRAMONT CIR
LITTLE ROCK AR
72223-3301
US

V. Phone/Fax

Practice location:
  • Phone: 501-766-6311
  • Fax: 479-227-2345
Mailing address:
  • Phone: 501-766-6311
  • Fax: 479-227-2345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License NumberE-8349
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE-8349
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE-8349
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: