Basic Information
| Provider Information | |||||||||
| NPI: | 1124089297 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VINES | ||||||||
| FirstName: | TROY | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3104 APACHE DR | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724017405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709322499 | ||||||||
| FaxNumber: | 8709322401 | ||||||||
| Practice Location | |||||||||
| Address1: | 2205 W PARKER RD | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724047778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709339250 | ||||||||
| FaxNumber: | 8709314790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 02/17/2017 | ||||||||
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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 | C-6684 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 109680001 | 05 | AR | MEDICAID |