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General NPI Number Information
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NPI Number | 1114734969
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Entity Type | Organization
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Legal Business Name | T W WAGNER INC
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Dates
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Enumeration Date | 12/16/2024
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Last Update Date | 12/19/2024
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Provider Practice Location Address
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Address Line | 730 GREENWOOD AVE
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City | LEPANTO
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State | AR
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Zip | 72354-3215
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Country | US
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Telephone | 870-475-3825
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 910
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City | MANILA
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State | AR
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Zip | 72442-0910
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Country | US
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Telephone | 870-561-3300
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Fax |
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Authorized Official
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Title or Position | OWNER/OPERATOR
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Name | TOMMY W WAGNER
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Credential | MD
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Telephone | 870-561-3300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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