Individual
KEITH ANIEL RUSSWORM JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
NP
Contact information
Practice address
1600 W 40TH AVE, PINE BLUFF, AR 71603-6301
(870) 541-7100
Mailing address
200 CORPORATE BLVD, LAFAYETTE, LA 70508-3870
(800) 893-9698
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
A005484
AR
Other
Enumeration date
01/15/2018
Last updated
01/25/2018
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