Healthcare Provider Details

I. General information

NPI: 1043968894
Provider Name (Legal Business Name): HENDERSON STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2022
Last Update Date: 03/15/2022
Certification Date: 03/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 HENDERSON ST
ARKADELPHIA AR
71999-0001
US

IV. Provider business mailing address

1100 HENDERSON ST
ARKADELPHIA AR
71999-0001
US

V. Phone/Fax

Practice location:
  • Phone: 870-230-5102
  • Fax:
Mailing address:
  • Phone: 870-230-5102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RENEE WALLS
Title or Position: INTERIM DIRECTOR
Credential: APRN
Phone: 870-230-5102