| T W Wagner Inc | |
|
3644 W State Highway 18 Manila AR 72442-8049 | |
| (870) 561-3300 | |
| (870) 561-3307 |
| Full Name | T W Wagner Inc |
|---|---|
| Speciality | Family Medicine |
| Location | 3644 W State Highway 18, Manila, Arkansas |
| Authorized Official Name and Position | Tommy W Wagner (OWNER) |
| Authorized Official Contact | 8705613300 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| T W Wagner Inc Po Box 910 Manila AR 72442-0910 Ph: (870) 561-3300 | T W Wagner Inc 3644 W State Highway 18 Manila AR 72442-8049 Ph: (870) 561-3300 |
| NPI Number | 1720183031 |
|---|---|
| Provider Enumeration Date | 09/13/2006 |
| Last Update Date | 07/22/2016 |
| Medicare PECOS PAC ID | 1153359096 |
|---|---|
| Medicare Enrollment ID | O20050830000950 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1720183031 | NPI | - | NPPES |
| 156106001 | Medicaid | AR |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | E3873 (Arkansas) | Primary |
| 363LF0000X | Nurse Practitioner - Family | A01771 (Arkansas) | Secondary |
| Provider Name | Tommy Wayne Wagner |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1952385064 PECOS PAC ID: 2264422195 Enrollment ID: I20040513000982 |
| Provider Name | Lacey Diane Poe |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1205069630 PECOS PAC ID: 3476609777 Enrollment ID: I20090928000401 |
| Provider Name | Victoria L Gamble |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1629201710 PECOS PAC ID: 3375689680 Enrollment ID: I20090929000679 |
| Provider Name | Brittany R Rose |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1326566357 PECOS PAC ID: 2860758208 Enrollment ID: I20171117001212 |
| Provider Name | Morgan Bliss Noble |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1285244178 PECOS PAC ID: 3577982552 Enrollment ID: I20200924000452 |
| Provider Name | Taylor S Long |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1326655416 PECOS PAC ID: 5294147294 Enrollment ID: I20201216001318 |
| Provider Name | Karley Sexton |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1114520491 PECOS PAC ID: 6103228291 Enrollment ID: I20210712004087 |
| Provider Name | Skiver Lynn Dilldine |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1790523447 PECOS PAC ID: 8325589856 Enrollment ID: I20240924001321 |
| Provider Name | Khali Houart |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1902624299 PECOS PAC ID: 4688107550 Enrollment ID: I20241030003282 |
| Provider Name | Jennifer Kyle Ross |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1720896947 PECOS PAC ID: 6204366412 Enrollment ID: I20250203003373 |
Shaneyfelt Clinic Primary Care Clinic Medicare: Not Enrolled in Medicare Practice Location: 105 S. Baltimore, Manila, AR 72442 Phone: 870-561-4421 Fax: 870-561-3434 | |
T W Wagner Inc Primary Care Clinic Medicare: Medicare Enrolled Practice Location: 3644 W State Highway 18, Manila, AR 72442 Phone: 870-561-3300 Fax: 870-561-3307 |