Provider Demographics
NPI:1720183031
Name:T W WAGNER INC
Entity Type:Organization
Organization Name:T W WAGNER INC
Other - Org Name:WAGNER MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:W
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:870-561-3300
Mailing Address - Street 1:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:MANILA
Mailing Address - State:AR
Mailing Address - Zip Code:72442-0910
Mailing Address - Country:US
Mailing Address - Phone:870-561-3300
Mailing Address - Fax:870-561-3307
Practice Address - Street 1:3644 W STATE HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:MANILA
Practice Address - State:AR
Practice Address - Zip Code:72442-8049
Practice Address - Country:US
Practice Address - Phone:870-561-3300
Practice Address - Fax:870-561-3307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3873207Q00000X
ARA01771363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR156106001Medicaid
AR156106001Medicaid