Basic Information
| Provider Information | |||||||||
| NPI: | 1891968293 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICHARDSON | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | EMMANUEL | ||||||||
| NamePrefix: | |||||||||
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| Credential: | D.O., E.D.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1960 | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724031960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709368000 | ||||||||
| FaxNumber: | 8709362228 | ||||||||
| Practice Location | |||||||||
| Address1: | 4802 E JOHNSON AVE | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724018413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709368000 | ||||||||
| FaxNumber: | 8709362228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2008 | ||||||||
| LastUpdateDate: | 10/18/2018 | ||||||||
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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 | 207P00000X | E-6218 | AR | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207L00000X | E-6218 | AR | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 179973003 | 05 | AR | MEDICAID |