# T W WAGNER INC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** WAGNER MEDICAL CLINIC
- **Organization subpart:** No

## Provider details

- **NPI number:** 1720183031
- **Authorized official:** TOMMY W WAGNER JR. MD (OWNER)
- **Authorized official phone:** (870) 561-3300

## Contact information

- **Practice address:** 3644 W STATE HIGHWAY 18, MANILA, AR 72442-8049
- **Practice address phone:** (870) 561-3300
- **Practice address fax:** (870) 561-3307
- **Mailing address:** PO BOX 910, MANILA, AR 72442-0910
- **Mailing address phone:** (870) 561-3300
- **Mailing address fax:** (870) 561-3307

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | E3873 | AR | Yes |
| 363LF0000X | Family Nurse Practitioner | A01771 | AR | — |

## Other

- **Enumeration date:** 09/13/2006
- **Last updated:** 07/22/2016

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 156106001 | — | AR |