Healthcare Provider Details

I. General information

NPI: 1104884386
Provider Name (Legal Business Name): MARK A WREN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 04/18/2024
Certification Date: 04/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4613 PARKWAY DR STE 1
TEXARKANA AR
71854-1142
US

IV. Provider business mailing address

4613 PARKWAY DR STE 1
TEXARKANA AR
71854-1142
US

V. Phone/Fax

Practice location:
  • Phone: 870-330-0496
  • Fax: 870-330-0499
Mailing address:
  • Phone: 870-330-0496
  • Fax: 870-330-0499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberE-0509
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberJ9450
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: