Provider Demographics
NPI:1598186009
Name:WESTERN ARKANSAS PRIMARY CARE
Entity Type:Organization
Organization Name:WESTERN ARKANSAS PRIMARY CARE
Other - Org Name:WESTERN ARKANSAS PRIMARY CARE 2
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LONNIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-965-8888
Mailing Address - Street 1:2617 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:AR
Mailing Address - Zip Code:72933-9637
Mailing Address - Country:US
Mailing Address - Phone:479-965-8888
Mailing Address - Fax:479-965-8889
Practice Address - Street 1:1069 S SHARPE AVE
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72927-4683
Practice Address - Country:US
Practice Address - Phone:479-965-8888
Practice Address - Fax:479-965-8889
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN ARKANSAS PRIMARY CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-31
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE1887208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1336577238OtherTRICARE
AR1336577238OtherTRICARE