Provider Demographics
NPI:1619321221
Name:SOUTHEAST ARKANSAS PRIMARY CARE ASSOCIATES
Entity Type:Organization
Organization Name:SOUTHEAST ARKANSAS PRIMARY CARE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:A
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:870-209-1601
Mailing Address - Street 1:3801 W 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-4774
Mailing Address - Country:US
Mailing Address - Phone:870-209-1601
Mailing Address - Fax:
Practice Address - Street 1:3801 W 28TH AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-4774
Practice Address - Country:US
Practice Address - Phone:870-209-1601
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004617363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty