Provider Demographics
NPI:1740731306
Name:WAGNER, KRISTEN LEIGH (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LEIGH
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:LEIGH
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:800 FAIR PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-1720
Mailing Address - Country:US
Mailing Address - Phone:501-978-2623
Mailing Address - Fax:
Practice Address - Street 1:800 FAIR PARK BLVD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204
Practice Address - Country:US
Practice Address - Phone:501-604-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant