Provider Demographics
NPI:1831391655
Name:MOONEYHAM, MANDY SUZANNE (PA-C)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:SUZANNE
Last Name:MOONEYHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:SUZANNE
Other - Last Name:SELVEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3053 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3417
Mailing Address - Country:US
Mailing Address - Phone:479-463-2000
Mailing Address - Fax:479-442-4518
Practice Address - Street 1:3053 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-3417
Practice Address - Country:US
Practice Address - Phone:479-463-2000
Practice Address - Fax:479-442-4518
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-329363AS0400X
MO2007002747363AS0400X
ARP-T0716363AS0400X
OK2266363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO219705OtherBLUE CROSS/BLUE SHIELD
MO502277007Medicaid
WA0223808OtherDEPARTMENT OF LABOR WA
MO000097457Medicare PIN
MO502277007Medicaid