Provider Demographics
NPI:1295706182
Name:SHORT, THEODORA L (ADVANCED PRACTICE NU)
Entity type:Individual
Prefix:MRS
First Name:THEODORA
Middle Name:L
Last Name:SHORT
Suffix:
Gender:F
Credentials:ADVANCED PRACTICE NU
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 130
Mailing Address - Street 2:
Mailing Address - City:RATCLIFF
Mailing Address - State:AR
Mailing Address - Zip Code:72951-0130
Mailing Address - Country:US
Mailing Address - Phone:479-635-5300
Mailing Address - Fax:479-635-4700
Practice Address - Street 1:9755 W. STATE HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:RATCLIFF
Practice Address - State:AR
Practice Address - Zip Code:72951-9000
Practice Address - Country:US
Practice Address - Phone:479-635-5300
Practice Address - Fax:479-635-2010
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01027363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
A004OtherTRICARE
A004OtherTRICARE
5U547Medicare PIN