NPIMap

Organization Active NPI

T W Wagner Inc

  • Rural Health Clinic/Center
  • Lepanto, AR
National Provider Identifier
1114734969
Registry record updated Dec 19, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 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
Last updated
Dec 19, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 19, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tommy W Wagner, MDNPI 1952385064
Title
Owner/Operator
Phone
(870) 561-3300

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

730 Greenwood Ave
Lepanto, AR 72354-3215

Mailing address

PO Box 910
Manila, AR 72442-0910
Phone (870) 561-3300

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20250228002698 AR Part A Provider - Rural Health Clinic 1153359096 Practice locations: Lepanto, AR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1114734969. Details of each certification follow.

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
CorporationProprietary
Enrollment address
730 Greenwood Ave
Lepanto, AR 72354-3215

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
04D1055975Wagner Medical Clinic730 Greenwood Ave, Lepanto, AR 72354Certificate of waiverJun 29, 2028

National Provider Directory

National Provider Directory
Tax ID family
T W Wagner Inc4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Locations

706 S Walton Blvd
Ste 8
Bentonville, AR 72712
Phone (870) 561-3300

Ownership & related parties

All disclosed owners & managing parties 1

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Tommy Wayne Wagner Individual 5% Or Greater Direct Ownership InterestPresident Oct 6, 2003 100%
Corporate OfficerPresident Oct 6, 2003 100%
W-2 Managing EmployeePresident Oct 6, 2003 100%

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

  • Tommy W Wagner, MD
    • Family Medicine Physician
    • Manila, AR
    • NPI 1952385064

    5% Or Greater Direct Ownership Interest, Corporate Officer, W-2 Managing Employee

    CMS ownership

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1734307200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1734566400000",
    "number": "1114734969",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 910",
            "city": "MANILA",
            "state": "AR",
            "postal_code": "724420910",
            "telephone_number": "870-561-3300"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "730 GREENWOOD AVE",
            "city": "LEPANTO",
            "state": "AR",
            "postal_code": "723543215",
            "telephone_number": "870-475-3825"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "T W WAGNER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-12-16",
        "last_updated": "2024-12-19",
        "certification_date": "2024-12-19",
        "status": "A",
        "authorized_official_last_name": "WAGNER",
        "authorized_official_first_name": "TOMMY",
        "authorized_official_middle_name": "W",
        "authorized_official_title_or_position": "OWNER/OPERATOR",
        "authorized_official_telephone_number": "870-561-3300",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Lepanto, AR

Sources for this page

Verify at the official NPI Registry.