Healthcare Provider Details

I. General information

NPI: 1902147689
Provider Name (Legal Business Name): NWA ADVANCED MEDICINE P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2013
Last Update Date: 03/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2035 N COLLEGE AVE SUITE 1
FAYETTEVILLE AR
72703-2613
US

IV. Provider business mailing address

PO BOX 698
FAYETTEVILLE AR
72702-0698
US

V. Phone/Fax

Practice location:
  • Phone: 479-571-2273
  • Fax:
Mailing address:
  • Phone: 479-571-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberE4245
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberE4245
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberE4245
License Number StateAR

VIII. Authorized Official

Name: RODNEY ROUTSONG
Title or Position: PRES
Credential: D.O.
Phone: 479-571-2273