Healthcare Provider Details

I. General information

NPI: 1760459648
Provider Name (Legal Business Name): SAMUEL RAY HISER APN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 04/03/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4802 E JOHNSON AVE
JONESBORO AR
72401-8413
US

IV. Provider business mailing address

404 COUNTY ROAD 376
BONO AR
72416-7556
US

V. Phone/Fax

Practice location:
  • Phone: 870-936-8000
  • Fax: 870-934-3626
Mailing address:
  • Phone: 870-219-1661
  • Fax: 870-333-5452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR065569
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberS01121
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberS001121
License Number StateAR
# 4
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberS001121
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: