Individual
DAYTON PARISH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
2710 S RIFE MEDICAL LN, ROGERS, AR 72758-1452
(479) 338-8000
(479) 986-3448
Mailing address
PO BOX 776084, CHICAGO, IL 60677-6084
(479) 338-8000
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
06/10/2026
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