Provider Demographics
NPI:1659436830
Name:WAGNER, ANTHONY MARK (FNP)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:MARK
Last Name:WAGNER
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
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Mailing Address - Street 1:1400 CENTERPOINT BLVD STE 158
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37932-1966
Mailing Address - Country:US
Mailing Address - Phone:865-374-5806
Mailing Address - Fax:865-374-9004
Practice Address - Street 1:210 SIMMONS ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801
Practice Address - Country:US
Practice Address - Phone:865-970-9800
Practice Address - Fax:865-983-4518
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN129889 NP363LF0000X
TN11134363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1514002Medicaid