Basic Information
Provider Information | |||||||||
NPI: | 1467641795 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PAINE | ||||||||
FirstName: | JORDANA | ||||||||
MiddleName: | BETH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10810 EXECUTIVE CENTER DR STE 100 | ||||||||
Address2: |   | ||||||||
City: | LITTLE ROCK | ||||||||
State: | AR | ||||||||
PostalCode: | 722114386 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016042695 | ||||||||
FaxNumber: | 5016042699 | ||||||||
Practice Location | |||||||||
Address1: | 10810 EXECUTIVE CENTER DR STE 100 | ||||||||
Address2: |   | ||||||||
City: | LITTLE ROCK | ||||||||
State: | AR | ||||||||
PostalCode: | 722114386 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016042695 | ||||||||
FaxNumber: | 5016042699 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/23/2007 | ||||||||
LastUpdateDate: | 08/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | J3988 | TX | N |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | E-15311 | AR | Y |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
ID | Type | State | Issuer | Description | 8GA442 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 8FY631 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | P01665507 | 01 |   | RAILROAD MEDICARE | OTHER | P01665538 | 01 |   | RAILROAD MEDICARE | OTHER | 348531002 | 05 | TX |   | MEDICAID |