Basic Information
| Provider Information | |||||||||
| NPI: | 1659436830 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | MARK | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 CENTERPOINT BLVD STE 158 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379321966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653745806 | ||||||||
| FaxNumber: | 8653749004 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 SIMMONS ST | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659709800 | ||||||||
| FaxNumber: | 8659834518 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 05/29/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN129889 NP | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 11134 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1514002 | 05 | TN | MEDICAID |