Healthcare Provider Details

I. General information

NPI: 1063345411
Provider Name (Legal Business Name): TYLOR SCOTT REEVES-WAGONER BSN, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 W 32ND ST
JOPLIN MO
64804-3503
US

IV. Provider business mailing address

3821 VALLEY DR
JOPLIN MO
64801-8373
US

V. Phone/Fax

Practice location:
  • Phone: 417-347-1111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2020031499
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: