Provider Demographics
NPI:1982921391
Name:GARNER, TRACE NATHANIEL (MD)
Entity Type:Individual
Prefix:
First Name:TRACE
Middle Name:NATHANIEL
Last Name:GARNER
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 1:10100 KANIS RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6202
Mailing Address - Country:US
Mailing Address - Phone:501-255-6000
Mailing Address - Fax:501-255-6400
Practice Address - Street 1:766 H L ROSS DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-5706
Practice Address - Country:US
Practice Address - Phone:870-412-4302
Practice Address - Fax:870-412-4178
Is Sole Proprietor?:No
Enumeration Date:2010-04-24
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-8037207RC0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07720835Medicaid