Healthcare Provider Details

I. General information

NPI: 1255912127
Provider Name (Legal Business Name): ELLE KARLI DYSON P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2010
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date: 11/09/2020
Reactivation Date: 04/20/2021

III. Provider practice location address

525 WESTERN AVE STE 305
CONWAY AR
72034-4982
US

IV. Provider business mailing address

525 WESTERN AVE STE 305
CONWAY AR
72034-4982
US

V. Phone/Fax

Practice location:
  • Phone: 501-358-6145
  • Fax: 501-504-6642
Mailing address:
  • Phone: 501-358-6145
  • Fax: 501-504-6642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA977
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: