Basic Information
| Provider Information | |||||||||
| NPI: | 1912369687 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAWN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | APN | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | RAWN | ||||||||
| OtherFirstName: | LISA | ||||||||
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| OtherCredential: | APN | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2024 ARKANSAS VALLEY DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722124166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012270700 | ||||||||
| FaxNumber: | 5012270744 | ||||||||
| Practice Location | |||||||||
| Address1: | 9601 BAPTIST HEALTH DR | ||||||||
| Address2: | MEDICAL TOWERS I STE 750 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012240200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2016 | ||||||||
| LastUpdateDate: | 08/30/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 20960 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | 20960 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LP2300X | 20960 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LA2200X | A004797 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | A004797 | AR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.