Healthcare Provider Details

I. General information

NPI: 1174138473
Provider Name (Legal Business Name): NICKOLAS MATTHEWS APRN-CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1014 W COLLIN RAYE DR
DE QUEEN AR
71832-2026
US

IV. Provider business mailing address

1088 CHAPEL HILL RD
DE QUEEN AR
71832-9013
US

V. Phone/Fax

Practice location:
  • Phone: 870-584-3000
  • Fax:
Mailing address:
  • Phone: 832-229-3711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number215774
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: