Healthcare Provider Details

I. General information

NPI: 1437679651
Provider Name (Legal Business Name): EVAN BRANSCUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 09/13/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 HWY 65 NORTH SUITE 200
HARRISON AR
72601-2737
US

IV. Provider business mailing address

PO BOX 802843
KANSAS CITY MO
64180-2843
US

V. Phone/Fax

Practice location:
  • Phone: 870-743-9744
  • Fax: 870-743-9746
Mailing address:
  • Phone: 417-730-6430
  • Fax: 417-269-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2018023700
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-13273
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: