Basic Information
| Provider Information | |||||||||
| NPI: | 1063891570 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SLATER | ||||||||
| FirstName: | JANTZEN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 550 | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794637775 | ||||||||
| FaxNumber: | 4794637187 | ||||||||
| Practice Location | |||||||||
| Address1: | 199 E. MAIN ST. | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727303077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792671001 | ||||||||
| FaxNumber: | 4792671026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2015 | ||||||||
| LastUpdateDate: | 07/19/2018 | ||||||||
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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 | 207Q00000X | 9865992-1205 | UT | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | E-11402 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.