Basic Information
| Provider Information | |||||||||
| NPI: | 1194095448 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARBEY | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HARRISON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726012911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704144760 | ||||||||
| FaxNumber: | 8704144990 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 NORTH MAIN | ||||||||
| Address2: | |||||||||
| City: | HARRISON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726012911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703652000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2012 | ||||||||
| LastUpdateDate: | 09/03/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA-463 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 5AJ41 | 01 | AR | AR BLUE CROSS | OTHER |