Provider Demographics
NPI:1295405421
Name:YUSTANA, NEONI S
Entity Type:Individual
Prefix:
First Name:NEONI
Middle Name:S
Last Name:YUSTANA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 TOWSON AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-4921
Mailing Address - Country:US
Mailing Address - Phone:479-709-7435
Mailing Address - Fax:479-709-4737
Practice Address - Street 1:1001 TOWSON AVE STE 300
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:479-709-7435
Practice Address - Fax:479-709-4737
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-19
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-1038363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant