Provider Demographics
NPI:1386685360
Name:WAGNER, NICHOLAS MARK (DPT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:MARK
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S MCKINLEY ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5202
Mailing Address - Country:US
Mailing Address - Phone:501-225-0181
Mailing Address - Fax:501-225-0384
Practice Address - Street 1:600 S MCKINLEY ST
Practice Address - Street 2:SUITE 210
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5202
Practice Address - Country:US
Practice Address - Phone:501-225-0181
Practice Address - Fax:501-225-0384
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2846225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y867OtherABCBS
AR5Y867OtherABCBS