Provider Demographics
NPI:1528721271
Name:KENDALL D. WAGNER, M.D., PLLC
Entity type:Organization
Organization Name:KENDALL D. WAGNER, M.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KENDALL
Authorized Official - Middle Name:DARREN
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-766-6311
Mailing Address - Street 1:8331 HOWARD HILL RD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72916-9787
Mailing Address - Country:US
Mailing Address - Phone:501-766-6311
Mailing Address - Fax:
Practice Address - Street 1:11300 ROBERTS BLVD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72916-6027
Practice Address - Country:US
Practice Address - Phone:000-000-0000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR202855001Medicaid