MEDICARE: KENDALL D. WAGNER, M.D., PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528721271
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENDALL D. WAGNER, M.D., PLLC

Provider Business Mailing Address
First Line	:	8331 HOWARD HILL RD
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72916-9787
Country	:	US
Telephone Number	:	501-766-6311
Fax Number	:

Provider Business Practice Location Address
First Line	:	11300 ROBERTS BLVD
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72916-6027
Country	:	US
Telephone Number	:	--
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. KENDALL DARREN WAGNER
Credential	:	MD
Telephone Number	:	501-766-6311

Provider Enumeration Date	:	10/20/2021
Last Update Date	:	10/20/2021

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