MEDICARE: ALYSSA BRIANNE SNOW PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	1689	MN
2	363A00000X	Physician Assistant	10001210	IN
3	363AS0400X	Surgical Physician Assistant	MA07081	PA
4	363AM0700X	Medical Physician Assistant	PA-734	AR

General Provider Information

NPI Number	:	1912214958
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALYSSA BRIANNE SNOW PA-C

Provider Business Mailing Address
First Line	:	2012 S PROMENADE BLVD
Second Line	:
City	:	ROGERS
State	:	AR
Zip	:	72758-9073
Country	:	US
Telephone Number	:	479-616-1485
Fax Number	:	479-239-0536

Provider Business Practice Location Address
First Line	:	2012 S PROMENADE BLVD
Second Line	:
City	:	ROGERS
State	:	AR
Zip	:	72758-9073
Country	:	US
Telephone Number	:	479-616-1485
Fax Number	:	479-239-0536

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2010
Last Update Date	:	05/25/2023

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