Healthcare Provider Details

I. General information

NPI: 1912143280
Provider Name (Legal Business Name): LINDA CASEY SIDES ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2008
Last Update Date: 12/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 W COURT STREET
JASPER AR
72641
US

IV. Provider business mailing address

502 W COURT STREET
JASPER AR
72641
US

V. Phone/Fax

Practice location:
  • Phone: 870-446-2203
  • Fax:
Mailing address:
  • Phone: 870-446-2203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberA02915ANP
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: