Healthcare Provider Details

I. General information

NPI: 1720183031
Provider Name (Legal Business Name): T W WAGNER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3644 W STATE HIGHWAY 18
MANILA AR
72442-8049
US

IV. Provider business mailing address

PO BOX 910
MANILA AR
72442-0910
US

V. Phone/Fax

Practice location:
  • Phone: 870-561-3300
  • Fax: 870-561-3307
Mailing address:
  • Phone: 870-561-3300
  • Fax: 870-561-3307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE3873
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA01771
License Number StateAR

VIII. Authorized Official

Name: TOMMY W WAGNER JR.
Title or Position: OWNER
Credential: MD
Phone: 870-561-3300