Healthcare Provider Details

I. General information

NPI: 1134748411
Provider Name (Legal Business Name): ANDREW LOYD OSMON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 06/05/2020
Certification Date: 06/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 PRINCE ST STE 4
CONWAY AR
72034-3701
US

IV. Provider business mailing address

28 WEATHERWOOD DR
GREENBRIER AR
72058-8816
US

V. Phone/Fax

Practice location:
  • Phone: 501-327-6665
  • Fax:
Mailing address:
  • Phone: 501-472-5907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number125382
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: