Provider Demographics
NPI:1861645301
Name:PAUL, PAT
Entity Type:Individual
Prefix:
First Name:PAT
Middle Name:
Last Name:PAUL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 E WOODBROOK DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3760
Mailing Address - Country:US
Mailing Address - Phone:479-463-7198
Mailing Address - Fax:479-463-5326
Practice Address - Street 1:3215 N NORTHHILLS BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4424
Practice Address - Country:US
Practice Address - Phone:479-463-7198
Practice Address - Fax:479-463-5326
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR198133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered