Basic Information
| Provider Information | |||||||||
| NPI: | 1821156035 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEPHROPATHOLOGY ASSOCIATES, PLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ARKANA LABORATORIES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 10810 EXECUTIVE CENTER DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722114386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016042695 | ||||||||
| FaxNumber: | 5016042699 | ||||||||
| Practice Location | |||||||||
| Address1: | 10810 EXECUTIVE CENTER DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722114386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016042695 | ||||||||
| FaxNumber: | 5016042699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 12/08/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LARSEN | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | PATRICK | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR, OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5016042695 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | MC-2034 | AR | N | Laboratories | Clinical Medical Laboratory | 207ZP0101X | MC-2034 | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
ID Information
| ID | Type | State | Issuer | Description | 272534 | 05 | OR | MEDICAID | L00307 | 05 | SC | MEDICAID | 912012200 | 05 | FL | MEDICAID | 95323287 | 05 | CO | MEDICAID | 368483 | 05 | AZ | MEDICAID | 807547100 | 05 | ID | MEDICAID | 3810017266B | 05 | WV | MEDICAID | 529911940 | 05 | AL | MEDICAID | N210291 | 01 | FL | WELLCARE, FL HEALTHEASE ONLY | OTHER | 1504795 | 05 | TN | MEDICAID | 210587601 | 05 | TX | MEDICAID | 200279440 A | 05 | OK | MEDICAID |