Provider Demographics
NPI:1912901992
Name:FARRIS, PAUL E (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:E
Last Name:FARRIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 E JOYCE BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-6297
Mailing Address - Country:US
Mailing Address - Phone:479-439-6110
Mailing Address - Fax:479-251-1676
Practice Address - Street 1:1706 E JOYCE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-6297
Practice Address - Country:US
Practice Address - Phone:479-439-6110
Practice Address - Fax:479-439-6110
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC7627174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR126334001Medicaid
AR5J569Medicare ID - Type Unspecified