Provider Demographics
NPI:1336613215
Name:WASHAM, GARY (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:WASHAM
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 ARNOLD PALMER DR
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-6401
Mailing Address - Country:US
Mailing Address - Phone:501-351-3299
Mailing Address - Fax:
Practice Address - Street 1:300 S SHACKLEFORD RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-5725
Practice Address - Country:US
Practice Address - Phone:501-918-0589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA006024363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily