Basic Information
| Provider Information | |||||||||
| NPI: | 1033193966 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PESNELL | ||||||||
| FirstName: | LARKUS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 S 2ND ST | ||||||||
| Address2: | PO BOX 497 | ||||||||
| City: | AUGUSTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720062309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703472534 | ||||||||
| FaxNumber: | 8703473492 | ||||||||
| Practice Location | |||||||||
| Address1: | 1127 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | VILONIA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721739525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017966740 | ||||||||
| FaxNumber: | 5017966744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 01/03/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | C4135 | AR | N | Allopathic & Osteopathic Physicians | Anesthesiology | 208D00000X | C-4135 | AR | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 100081520A | 05 | OK | MEDICAID | 106481001 | 05 | AR | MEDICAID | 770119701 | 01 | AR | ARKANSAS BREASTCARE | OTHER |