Basic Information
| Provider Information | |||||||||
| NPI: | 1962431460 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAULSON | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8158 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727030003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795823366 | ||||||||
| FaxNumber: | 4795825843 | ||||||||
| Practice Location | |||||||||
| Address1: | 63 W SUNBRIDGE DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727031825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795823366 | ||||||||
| FaxNumber: | 4795825843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 12/08/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | E-2446 | AR | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 140580001 | 05 | AR | MEDICAID | 5L405 | 01 | AR | AR BC/BS | OTHER | P00315084 | 01 | AR | RR MCR | OTHER |