Basic Information
| Provider Information | |||||||||
| NPI: | 1578780946 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUNNINGHAM | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | ELIAS | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP, BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14801 PARK RIDGE DRIVE | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792956325 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4253 N CROSSOVER RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795215731 | ||||||||
| FaxNumber: | 4794422563 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 08/14/2017 | ||||||||
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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 | 363LP0808X | 0057700 | OK | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | A03250 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 200109330A | 05 | OK | MEDICAID |