Provider Demographics
NPI:1497376453
Name:LENZEN, ROSS
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:LENZEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N 3RD ST STE 1
Mailing Address - Street 2:
Mailing Address - City:DARDANELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72834-3802
Mailing Address - Country:US
Mailing Address - Phone:479-229-6191
Mailing Address - Fax:479-229-6194
Practice Address - Street 1:200 N 3RD ST STE 1
Practice Address - Street 2:
Practice Address - City:DARDANELLE
Practice Address - State:AR
Practice Address - Zip Code:72834-3802
Practice Address - Country:US
Practice Address - Phone:479-229-6191
Practice Address - Fax:479-229-6194
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-30
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE15200207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine