Provider Demographics
NPI:1790100329
Name:ABBOTT, RANDY (FNP)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:ABBOTT
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 MOUNT TABOR RD
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-9506
Mailing Address - Country:US
Mailing Address - Phone:501-658-1451
Mailing Address - Fax:
Practice Address - Street 1:1815 MOUNT TABOR RD
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-9506
Practice Address - Country:US
Practice Address - Phone:501-658-1451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA003839363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily