Provider Demographics
NPI:1922339167
Name:WAGNER, NATHAN S (DC)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:S
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3105 NE 11TH ST
Mailing Address - Street 2:STE 3
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-9127
Mailing Address - Country:US
Mailing Address - Phone:479-899-6658
Mailing Address - Fax:479-899-6685
Practice Address - Street 1:4608 W WALNUT ST STE A
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-1404
Practice Address - Country:US
Practice Address - Phone:479-899-6658
Practice Address - Fax:479-899-6685
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-28
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR15713111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor