Healthcare Provider Details

I. General information

NPI: 1285859009
Provider Name (Legal Business Name): REX D WAGGONER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 W MAPLE AVE
SPRINGDALE AR
72764-5335
US

IV. Provider business mailing address

PO BOX 580
SPRINGDALE AR
72765-0580
US

V. Phone/Fax

Practice location:
  • Phone: 479-751-5711
  • Fax:
Mailing address:
  • Phone: 479-751-6352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC00272
License Number StateAR

VIII. Authorized Official

Name: MR. REX D WAGGONER
Title or Position: PRESIDENT
Credential: CRNA
Phone: 479-751-6352