Provider Demographics
NPI:1114428984
Name:BROWN, PAUL THOMAS (RD, LD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:THOMAS
Last Name:BROWN
Suffix:
Gender:M
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3082 W JEWELL RD APT 1
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-1586
Mailing Address - Country:US
Mailing Address - Phone:501-350-1066
Mailing Address - Fax:
Practice Address - Street 1:3082 W JEWELL RD APT 1
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-1586
Practice Address - Country:US
Practice Address - Phone:501-350-1066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR86058528133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered