Provider Demographics
NPI:1568515930
Name:WAGGONER, TARA LISA (FNP, APN-BC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LISA
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:FNP, APN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4203 SANDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7833
Mailing Address - Country:US
Mailing Address - Phone:870-910-0436
Mailing Address - Fax:
Practice Address - Street 1:333 STADIUM BLVD.
Practice Address - Street 2:SUITE B
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401
Practice Address - Country:US
Practice Address - Phone:870-972-2054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01852363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARQ42646Medicare UPIN