Provider Demographics
NPI:1982009395
Name:MISSION FAMILY PRACTICE PLLC
Entity Type:Organization
Organization Name:MISSION FAMILY PRACTICE PLLC
Other - Org Name:MISSION FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:BONNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-571-6000
Mailing Address - Street 1:PO BOX 3678
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-3678
Mailing Address - Country:US
Mailing Address - Phone:479-571-6000
Mailing Address - Fax:479-571-3344
Practice Address - Street 1:2630 E CITIZENS DR
Practice Address - Street 2:SUITE #13
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4797
Practice Address - Country:US
Practice Address - Phone:479-571-6000
Practice Address - Fax:479-571-3344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-28
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-7247207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR113998001Medicaid
AR51916OtherUNSPECIFIED
ARP00200111OtherRR MCR
AR51916OtherAR BC/BS
ARP00200111OtherRR MCR
ARD04572Medicare UPIN
AR51916OtherUNSPECIFIED
AR113998001Medicaid