Provider Demographics
NPI:1932664067
Name:FAUGHN, PHILIP RAY (APRN)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:RAY
Last Name:FAUGHN
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 1:5403 SHAD DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-9419
Mailing Address - Country:US
Mailing Address - Phone:870-919-0648
Mailing Address - Fax:
Practice Address - Street 1:225 E JACKSON AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3119
Practice Address - Country:US
Practice Address - Phone:870-207-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-03
Last Update Date:2019-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA006105363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARA006105Medicaid