Healthcare Provider Details

I. General information

NPI: 1962110031
Provider Name (Legal Business Name): WHITE OAK MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2022
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11442 SR 27
HECTOR AR
72843-9102
US

IV. Provider business mailing address

11442 SR 27
HECTOR AR
72843-9102
US

V. Phone/Fax

Practice location:
  • Phone: 479-264-4455
  • Fax:
Mailing address:
  • Phone: 479-284-2012
  • Fax: 479-284-0395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MARANDA MOORE
Title or Position: MANAGER
Credential: APN
Phone: 479-284-2012