MEDICARE: MR. REX DWAYNE WAGGONER CRNA

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	367500000X	Certified Registered Nurse Anesthetist	26949	AR

General Provider Information

NPI Number	:	1790769164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. REX DWAYNE WAGGONER CRNA

Provider Business Mailing Address
First Line	:	1307 OVERO CIR
Second Line	:
City	:	SPRINGDALE
State	:	AR
Zip	:	72762-2129
Country	:	US
Telephone Number	:	479-756-2252
Fax Number	:	479-751-6352

Provider Business Practice Location Address
First Line	:	609 W MAPLE AVE
Second Line	:
City	:	SPRINGDALE
State	:	AR
Zip	:	72764-5335
Country	:	US
Telephone Number	:	479-757-5711
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	07/09/2007

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