Provider Demographics
NPI:1407397458
Name:TOLLESON, MICHAEL (RN)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:TOLLESON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 FAIR OAKS LN
Mailing Address - Street 2:
Mailing Address - City:HOPE
Mailing Address - State:AR
Mailing Address - Zip Code:71801-9706
Mailing Address - Country:US
Mailing Address - Phone:870-703-3420
Mailing Address - Fax:
Practice Address - Street 1:2600 SAINT MICHAEL DR
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-5220
Practice Address - Country:US
Practice Address - Phone:903-614-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-09
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR87064163W00000X
TXAP134058363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse