Provider Demographics
NPI:1790769164
Name:WAGGONER, REX DWAYNE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:REX
Middle Name:DWAYNE
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 OVERO CIR
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-2129
Mailing Address - Country:US
Mailing Address - Phone:479-756-2252
Mailing Address - Fax:479-751-6352
Practice Address - Street 1:609 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-5335
Practice Address - Country:US
Practice Address - Phone:479-757-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR26949367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR59931Medicare ID - Type Unspecified