Individual
CHARLES WESLEY WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
12609 SAINT CHARLES BLVD, LITTLE ROCK, AR 72211-2227
(501) 680-0738
Mailing address
1 CHILDRENS WAY, LITTLE ROCK, AR 72202-3500
(501) 364-1447
Taxonomy
Speciality
Code
Description
License number
State
2086S0120X
Pediatric Surgery Physician
Primary
N-7036
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
N-7036
GENERAL PRACTICE
AR
05
—
N-7036
—
AR
Enumeration date
10/18/2022
Last updated
10/18/2022
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