Healthcare Provider Details

I. General information

NPI: 1700106549
Provider Name (Legal Business Name): SHIROLYN MOFFETT M.D.,P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 06/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 W SHERMAN AVE SUITE D
HARRISON AR
72601-2743
US

IV. Provider business mailing address

715 W SHERMAN AVE SUITE D
HARRISON AR
72601-2743
US

V. Phone/Fax

Practice location:
  • Phone: 870-204-5129
  • Fax: 870-204-5131
Mailing address:
  • Phone: 870-204-5129
  • Fax: 870-204-5131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberE0693
License Number StateAR

VIII. Authorized Official

Name: DR. SHIROLYN RUTH MOFFETT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 870-204-5129