Healthcare Provider Details

I. General information

NPI: 1003355447
Provider Name (Legal Business Name): LEROY MAUPIN JR. APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2017
Last Update Date: 02/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 VIRGINIA DR
BATESVILLE AR
72501-7329
US

IV. Provider business mailing address

407 VIRGINIA DR
BATESVILLE AR
72501-7329
US

V. Phone/Fax

Practice location:
  • Phone: 870-793-4200
  • Fax: 870-698-1353
Mailing address:
  • Phone: 870-793-4200
  • Fax: 870-698-1353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberA005035
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: