Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2200X | Nurse Practitioner - Adult Health | A005035 | AR |
NPI | 1003355447 |
---|---|
Provider Name | Mr. Leroy Maupin JR. |
First Address | Batesville, AR 72501-7329 |
Second Address | Batesville, AR 72501-7329 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/02/2017 |
Last Update Date | 17/02/2017 |