Basic Information
| Provider Information | |||||||||
| NPI: | 1407046220 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERBST | ||||||||
| FirstName: | AUNNA | ||||||||
| MiddleName: | CANNON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 700 SE PLAZA AVE | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727123003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797154645 | ||||||||
| FaxNumber: | 9185795762 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 SE PLAZA AVE | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727123003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797154645 | ||||||||
| FaxNumber: | 9185795762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2007 | ||||||||
| LastUpdateDate: | 01/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4647 | OK | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | E11897 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200204840A | 01 | OK | OSU ADJ | OTHER | 200204840B | 05 | OK | MEDICAID | 200470610D | 01 | OK | OSU-GROUP | OTHER | 200505990B | 05 | OK | MEDICAID |