Basic Information
Provider Information | |||||||||
NPI: | 1699703496 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SEXTON | ||||||||
FirstName: | JON | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1523 | ||||||||
Address2: |   | ||||||||
City: | FAYETTEVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 727021523 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4795218200 | ||||||||
FaxNumber: | 4795827310 | ||||||||
Practice Location | |||||||||
Address1: | 3344 N FUTRALL DR | ||||||||
Address2: |   | ||||||||
City: | FAYETTEVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 727034057 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4795218200 | ||||||||
FaxNumber: | 4795827310 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/29/2006 | ||||||||
LastUpdateDate: | 06/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | R-4164 | AR | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | 119310001 | 05 | AR |   | MEDICAID | P00189855 | 01 | AR | RR MCR | OTHER | 100222050A | 05 | OK |   | MEDICAID | 54611 | 01 | AR | AR BC/BS | OTHER |