Provider Demographics
NPI:1952385064
Name:WAGNER, TOMMY W (MD)
Entity Type:Individual
Prefix:
First Name:TOMMY
Middle Name:W
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:MANILA
Mailing Address - State:AR
Mailing Address - Zip Code:72442
Mailing Address - Country:US
Mailing Address - Phone:870-561-3300
Mailing Address - Fax:870-561-3307
Practice Address - Street 1:3644 W ST HWY 18
Practice Address - Street 2:
Practice Address - City:MANILA
Practice Address - State:AR
Practice Address - Zip Code:72442
Practice Address - Country:US
Practice Address - Phone:870-561-3300
Practice Address - Fax:870-561-3307
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3873207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR156106001Medicaid
ARI03046Medicare UPIN
AR5M801Medicare PIN