Healthcare Provider Details

I. General information

NPI: 1821104449
Provider Name (Legal Business Name): VAMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N COLLEGE AVE
FAYETTEVILLE AR
72703-1944
US

IV. Provider business mailing address

1621 N CHARLEE AVE
FAYETTEVILLE AR
72703-3066
US

V. Phone/Fax

Practice location:
  • Phone: 479-443-4301
  • Fax: 479-587-5996
Mailing address:
  • Phone: 479-444-7376
  • Fax: 479-587-5996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License NumberPA140
License Number StateAR

VIII. Authorized Official

Name: MR. JON SCOTT KELLER
Title or Position: PHYSICIAN ASST
Credential: PA
Phone: 479-443-4301