Provider Demographics
NPI:1811578701
Name:WAGONER PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:WAGONER PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:LEANN
Authorized Official - Last Name:WAGONER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-CNP
Authorized Official - Phone:870-283-2554
Mailing Address - Street 1:1477 HIGHWAY 167
Mailing Address - Street 2:
Mailing Address - City:EVENING SHADE
Mailing Address - State:AR
Mailing Address - Zip Code:72532-9497
Mailing Address - Country:US
Mailing Address - Phone:870-283-2554
Mailing Address - Fax:
Practice Address - Street 1:1477 HIGHWAY 167
Practice Address - Street 2:
Practice Address - City:EVENING SHADE
Practice Address - State:AR
Practice Address - Zip Code:72532-9497
Practice Address - Country:US
Practice Address - Phone:870-283-2554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty