Provider Demographics
NPI:1417306580
Name:ODOM, EMILEE (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILEE
Middle Name:
Last Name:ODOM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4261 STOCKTON DRIVE SUITE LL100
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72117
Mailing Address - Country:US
Mailing Address - Phone:501-975-7456
Mailing Address - Fax:501-978-1822
Practice Address - Street 1:9601 BAPTIST HEALTH DR STE 860
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205
Practice Address - Country:US
Practice Address - Phone:501-975-7455
Practice Address - Fax:501-975-3631
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-716363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR218864795Medicaid