Provider Demographics
NPI:1407046220
Name:HERBST, AUNNA CANNON (DO)
Entity Type:Individual
Prefix:DR
First Name:AUNNA
Middle Name:CANNON
Last Name:HERBST
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SE PLAZA AVE
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-3003
Mailing Address - Country:US
Mailing Address - Phone:479-715-4645
Mailing Address - Fax:918-579-5762
Practice Address - Street 1:700 SE PLAZA AVE
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3003
Practice Address - Country:US
Practice Address - Phone:479-715-4645
Practice Address - Fax:918-579-5762
Is Sole Proprietor?:No
Enumeration Date:2007-07-27
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4647207Q00000X
ARE11897207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200204840AOtherOSU ADJ
OK200204840BMedicaid
OK200470610DOtherOSU-GROUP
OK200505990BMedicaid
OK200470610DOtherOSU-GROUP
OK200204840AOtherOSU ADJ
OK200204840BMedicaid
OK200204840BMedicaid