Healthcare Provider Details

I. General information

NPI: 1811333206
Provider Name (Legal Business Name): ANTHONY TYLER MANNING M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2013
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 WESTERN AVE STE 203
CONWAY AR
72034-4980
US

IV. Provider business mailing address

525 WESTERN AVE STE 203
CONWAY AR
72034-4980
US

V. Phone/Fax

Practice location:
  • Phone: 501-327-4828
  • Fax: 501-327-6899
Mailing address:
  • Phone: 501-327-4828
  • Fax: 501-327-6899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberBP10047355
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberE-10862
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: