T W Wagner Inc
Organization Active NPI Rural Health Clinic/Center · Lepanto, AR
NPI 1114734969 · NPPES record last updated Dec 19, 2024
Key facts
- NPI
- 1114734969
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- T W WAGNER INC
- Practice address
- 730 Greenwood Ave
Lepanto, AR 72354-3215 - Phone
- (870) 475-3825
- NPI assigned
- Dec 16, 2024
- Organization subpart
- No
Authorized official
- Name
- Tommy W Wagner, MD
- Title
- Owner/Operator
- Phone
- (870) 561-3300
Owners & managing parties with NPI records 1
-
Tommy W Wagner, MD
Other NPIs with the same Medicare PAC ID 2
Corporate family (same tax ID) 3
Practitioners 9
-
Leah Gathright, CPNP-PC, FNP-C
-
Khali Houart, APRN
-
Morgan Bliss Noble, APRN
-
Brittany Rose, NP-C
-
Misty L Shatley, P.A.-C
-
Tommy W Wagner, MD
-
Laurell A Conder, NP-C
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 04D1055975 | Wagner Medical Clinic | Certificate of waiver | Jun 29, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in AR
Rural health clinic certification: CCN 043961
- Legal name
- T W WAGNER INC
- Doing business as
- WAGNER MEDICAL CLINIC
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Jan 30, 2026
- Last certification
- Jan 30, 2026
- Ownership / control type
- 1B
- Organization structure
- Corporation · Proprietary
- Enrollment address
- 730 Greenwood Ave
Lepanto, AR 72354-3215
All disclosed owners & managing parties 1
| Name | Role | Since | Share |
|---|---|---|---|
| Tommy Wayne Wagner |
5% Or Greater Direct Ownership Interest |
Oct 6, 2003 | 100% |
| Corporate Officer |
Oct 6, 2003 | 100% | |
| W-2 Managing Employee |
Oct 6, 2003 | 100% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20250228002698 | AR | Part a Provider - Rural Health Clinic | 1153359096 | Practice locations: Lepanto, AR |
National Provider Directory
- Tax ID family
- T W Wagner Inc
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | |||
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
730 Greenwood Ave
Lepanto, AR 72354-3215
Mailing address
PO Box 910
Manila, AR 72442-0910
Phone (870) 561-3300
Other providers in Lepanto, AR
- Mike Miller
- David Smith
- Southern Health and Wellness, Inc
- Ashley Jordan Staggs
- Regina Strop
- T W Wagner Inc
- Tri County Medical Transit LLC.
All providers in Lepanto, AR · Rural Health Clinic/Center in Arkansas
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 19, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.