Provider Demographics
NPI:1871935049
Name:WAGNER, MAEGAN LYNN (ANP)
Entity type:Individual
Prefix:MRS
First Name:MAEGAN
Middle Name:LYNN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 763
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654-0763
Mailing Address - Country:US
Mailing Address - Phone:870-425-5464
Mailing Address - Fax:870-425-5465
Practice Address - Street 1:2062 HIGHWAY 62 W
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-7656
Practice Address - Country:US
Practice Address - Phone:870-425-5464
Practice Address - Fax:870-425-5465
Is Sole Proprietor?:No
Enumeration Date:2013-07-29
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA003922363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR199560758Medicaid