Provider Demographics
NPI:1811401193
Name:FAWBUSH, NATHAN GERRELL (APRN)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:GERRELL
Last Name:FAWBUSH
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 1:15111 HIGHWAY 165
Mailing Address - Street 2:
Mailing Address - City:SCOTT
Mailing Address - State:AR
Mailing Address - Zip Code:72142
Mailing Address - Country:US
Mailing Address - Phone:501-552-7999
Mailing Address - Fax:
Practice Address - Street 1:15111 HIGHWAY 165
Practice Address - Street 2:
Practice Address - City:SCOTT
Practice Address - State:AR
Practice Address - Zip Code:72142
Practice Address - Country:US
Practice Address - Phone:501-552-7999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-25
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005332363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily