Individual
DAYTON PARISH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
609 W MAPLE AVE, SPRINGDALE, AR 72764-5335
(479) 751-5711
Mailing address
3700 SW MODERN WAY APT 206, BENTONVILLE, AR 72713-2032
(479) 495-1371
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA-1065
AR
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
08/14/2020
Last updated
07/25/2022
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