Basic Information
| Provider Information | |||||||||
| NPI: | 1316918576 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | J.P. WORNOCK M.D. P.A. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PRIMECARE MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 400 S MAIN ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | SEARCY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721437801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012799000 | ||||||||
| FaxNumber: | 5012799011 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 S MAIN ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | SEARCY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721437801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012799000 | ||||||||
| FaxNumber: | 5012799011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 03/22/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WORNOCK | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5012799000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | E1057 | AR | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 150895002 | 05 | AR | MEDICAID |