Provider Demographics
NPI:1902205248
Name:MAHANA, BRIAN D
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
Last Name:MAHANA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 655
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-0655
Mailing Address - Country:US
Mailing Address - Phone:479-463-7775
Mailing Address - Fax:479-463-7187
Practice Address - Street 1:3211 N. NORTH HILLS BLVD.
Practice Address - Street 2:SUITE 110
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-571-4338
Practice Address - Fax:479-571-4015
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004167363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily