Basic Information
| Provider Information | |||||||||
| NPI: | 1386614097 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WORNOCK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WORNOCK | ||||||||
| OtherFirstName: | JP | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 400 S MAIN ST | ||||||||
| Address2: | STE 100 | ||||||||
| City: | SEARCY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721437800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012799000 | ||||||||
| FaxNumber: | 5012799011 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 S MAIN ST | ||||||||
| Address2: | STE 100 | ||||||||
| City: | SEARCY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721437800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012799000 | ||||||||
| FaxNumber: | 5012799011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 12/02/2013 | ||||||||
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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 | 207Q00000X | E1057 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 130020001 | 05 | AR | MEDICAID |