Provider Demographics
NPI:1003532268
Name:WAGNER, CHARLES WESLEY (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:WESLEY
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CHILDRENS WAY
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-3500
Mailing Address - Country:US
Mailing Address - Phone:501-364-1447
Mailing Address - Fax:
Practice Address - Street 1:12609 SAINT CHARLES BLVD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-2227
Practice Address - Country:US
Practice Address - Phone:501-680-0738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN-70362086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARN-7036OtherGENERAL PRACTICE
ARN-7036Medicaid