Organization
PATHOLOGY SERVICES LABORATORY PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. CHRISTINA ANN JETTON M.D. (PRESIDENT)
(479) 968-6781
Entity
Organization
Contact information
Practice address
1430 WEST C STREET, RUSSELLVILLE, AR 72811-0925
(479) 968-6781
(479) 968-3074
Mailing address
PO BOX 925, RUSSELLVILLE, AR 72811-0925
(479) 968-6781
(479) 968-3074
Taxonomy
Speciality
Code
Description
License number
State
207ZP0102X
Anatomic Pathology & Clinical Pathology Physician
—
—
291U00000X
Clinical Medical Laboratory
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
103882709
—
AR
01
—
770091902
BREASTCARE
—
01
—
MC0330
LICENSE NUMBER
AR
Enumeration date
11/20/2006
Last updated
05/31/2024
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