Provider Demographics
NPI:1578780946
Name:CUNNINGHAM, THOMAS ELIAS (APRN)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:ELIAS
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14801 PARK RIDGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745
Mailing Address - Country:US
Mailing Address - Phone:479-295-6325
Mailing Address - Fax:
Practice Address - Street 1:5305 W VILLAGE PKWY STE 12
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8116
Practice Address - Country:US
Practice Address - Phone:479-480-4892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0057700363LP0808X
ARA03250363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200109330AMedicaid