Healthcare Provider Details

I. General information

NPI: 1093209090
Provider Name (Legal Business Name): AUSTIN AXLEY COLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2018
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 CLUB LN
CONWAY AR
72034-3681
US

IV. Provider business mailing address

5760 GRAND TETON LN
CONWAY AR
72034-7623
US

V. Phone/Fax

Practice location:
  • Phone: 501-329-1510
  • Fax:
Mailing address:
  • Phone: 864-867-8111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number94-11281
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberE-18048
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: