Provider Demographics
NPI:1053314203
Name:BISE, CYGNET A
Entity Type:Individual
Prefix:
First Name:CYGNET
Middle Name:A
Last Name:BISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CYGNET
Other - Middle Name:A
Other - Last Name:SCHROEDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 3363
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72913-3363
Mailing Address - Country:US
Mailing Address - Phone:479-478-8555
Mailing Address - Fax:479-478-8568
Practice Address - Street 1:1001 TOWSON AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-4921
Practice Address - Country:US
Practice Address - Phone:479-478-8555
Practice Address - Fax:479-478-8555
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2010-11-11
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-21
Provider Licenses
StateLicense IDTaxonomies
ARR4158208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR149716002Medicaid
AR4102586OtherAETNA
AR250014112OtherRAIL ROAD MEDICARE
OK100174420BMedicaid
ARB18005Medicare UPIN
AR4102586OtherAETNA