Basic Information
| Provider Information | |||||||||
| NPI: | 1770534703 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL ASSOCIATES OF NORTHWEST ARKANSAS PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1523 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727021523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795716038 | ||||||||
| FaxNumber: | 4795820222 | ||||||||
| Practice Location | |||||||||
| Address1: | 3302 N NORTHHILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795823366 | ||||||||
| FaxNumber: | 4795716572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 05/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | JORDIN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CIO | ||||||||
| AuthorizedOfficialTelephone: | 4795716780 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 363LW0102X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 207VG0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 5F220 | 01 | AR | AR BC/BS | OTHER | 156352002 | 05 | AR | MEDICAID |