Healthcare Provider Details

I. General information

NPI: 1790484582
Provider Name (Legal Business Name): JON LAWRENCE FAULKNER HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2023
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3484 W WEDINGTON DR STE 2
FAYETTEVILLE AR
72704-7164
US

IV. Provider business mailing address

3484 W WEDINGTON DR STE 2
FAYETTEVILLE AR
72704-7164
US

V. Phone/Fax

Practice location:
  • Phone: 479-396-4800
  • Fax:
Mailing address:
  • Phone: 479-396-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number623
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: