Basic Information
| Provider Information | |||||||||
| NPI: | 1538485941 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRIGHTWELL | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | LUKE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 S 2ND ST | ||||||||
| Address2: | PO BOX 497 | ||||||||
| City: | AUGUSTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720062309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703472534 | ||||||||
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| Practice Location | |||||||||
| Address1: | 54 TATE SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725568633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703685030 | ||||||||
| FaxNumber: | 8703685032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2010 | ||||||||
| LastUpdateDate: | 11/07/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA-407 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 197619795 | 05 | AR | MEDICAID |