Provider Demographics
NPI:1396793170
Name:SALAZAR, MARY ANN (ANP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:SALAZAR
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 WEST POPLAR STREET
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756
Mailing Address - Country:US
Mailing Address - Phone:479-636-9235
Mailing Address - Fax:479-631-0374
Practice Address - Street 1:1233 WEST POPLAR STREET
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756
Practice Address - Country:US
Practice Address - Phone:479-636-9235
Practice Address - Fax:479-631-0374
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01266363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR155331758Medicaid
AR155331758Medicaid
AR5Y084Medicare ID - Type Unspecified