Provider Demographics
NPI:1760459648
Name:HISER, SAMUEL RAY (APN)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:RAY
Last Name:HISER
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 COUNTY ROAD 376
Mailing Address - Street 2:
Mailing Address - City:BONO
Mailing Address - State:AR
Mailing Address - Zip Code:72416-7556
Mailing Address - Country:US
Mailing Address - Phone:870-219-1661
Mailing Address - Fax:870-333-5452
Practice Address - Street 1:4802 E JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-8413
Practice Address - Country:US
Practice Address - Phone:870-936-8000
Practice Address - Fax:870-934-3626
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR065569163W00000X
ARS01121363L00000X
ARS001121363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q57649Medicare UPIN
AR5Y600Medicare PIN
AR5Y600Medicare PIN