Basic Information
| Provider Information | |||||||||
| NPI: | 1184047730 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | TODD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 497 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720060497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703472534 | ||||||||
| FaxNumber: | 8703473492 | ||||||||
| Practice Location | |||||||||
| Address1: | 606 W WILBUR MILLS AVE | ||||||||
| Address2: | |||||||||
| City: | KENSETT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720829051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017425697 | ||||||||
| FaxNumber: | 5017423031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2014 | ||||||||
| LastUpdateDate: | 06/27/2019 | ||||||||
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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 | 363LF0000X | ATP-000613 | AR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | A004077 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 202081758 | 05 | AR | MEDICAID |