Individual
GANNON B RANDOLPH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1800 SE MOBERLY LN, BENTONVILLE, AR 72712-7017
(479) 521-2752
(479) 521-4603
Mailing address
3317 N WIMBERLY DR, FAYETTEVILLE, AR 72703-4056
(479) 521-2752
(479) 521-4603
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
E5957
AR
207XS0117X
Orthopaedic Surgery of the Spine Physician
Primary
E5957
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1176259001
—
AR
Enumeration date
08/20/2006
Last updated
07/12/2021
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