Organization Name: | T W WAGNER INC |
NPI Number: | 1720183031 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | TOMMY W WAGNER (OWNER) |
Mailing Address: | 434 Hwy 18 Bypass Manila |
State: | AR US |
Postal Code: | 72442 |
Phone Number: | 8705613300 |
Fax Number: | 8705613307 |
NPI Enumeration Date: | 09/13/2006 |
NPI Last Update Date: | 05/28/2008 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363LF0000X |
License Number: | A01771 |
Healthcare Provider Taxonomy: (Secondary) | N |
State: | AR |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Nurse Practitioner |
Taxonomy Specialization: | Family |
Taxonomy Definition: |