Healthcare Provider Details

I. General information

NPI: 1184211187
Provider Name (Legal Business Name): ETHAN PEARSON MSN, APRN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2020
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7001 ROGERS AVE
FORT SMITH AR
72903-4073
US

IV. Provider business mailing address

476954 E 1094 RD
ROLAND OK
74954-5061
US

V. Phone/Fax

Practice location:
  • Phone: 479-314-6000
  • Fax:
Mailing address:
  • Phone: 479-926-6037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number214768
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201449
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number132425
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: