=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699789008
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM GLYN WAGNON MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2006
-----------------------------------------------------
Last Update Date | 11/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6200 N LA CHOLLA BLVD
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85741-3529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-742-9000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3810 CENTRAL AVE SUITE H
-----------------------------------------------------
City | HOT SPRINGS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71913-6921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-525-5840
-----------------------------------------------------
Fax | 501-525-1762
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | C5842
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------