Healthcare Provider Details

I. General information

NPI: 1679176002
Provider Name (Legal Business Name): CORY ANDREW MCMAHON APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2020
Last Update Date: 08/07/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N CLIFTON ST
FORDYCE AR
71742-3026
US

IV. Provider business mailing address

200 SALVATION LN
RISON AR
71665-9604
US

V. Phone/Fax

Practice location:
  • Phone: 870-352-6354
  • Fax: 870-352-6361
Mailing address:
  • Phone: 870-723-1243
  • Fax: 870-352-8498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number213428
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: