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General NPI Number Information
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NPI Number | 1285859009
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Entity Type | Organization
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Legal Business Name | REX D WAGGONER PA
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Dates
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Enumeration Date | 04/16/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 609 W MAPLE AVE
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City | SPRINGDALE
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State | AR
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Zip | 72764-5335
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Country | US
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Telephone | 479-751-5711
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 580
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City | SPRINGDALE
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State | AR
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Zip | 72765-0580
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Country | US
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Telephone | 479-751-6352
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. REX D WAGGONER
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Credential | CRNA
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Telephone | 479-751-6352
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | C00272
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License Number State | AR
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