Healthcare Provider Details

I. General information

NPI: 1558822189
Provider Name (Legal Business Name): ANDREA FA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 KANIS RD STE 501
LITTLE ROCK AR
72205-6389
US

IV. Provider business mailing address

11001 EXECUTIVE CENTER DR STE 200
LITTLE ROCK AR
72211-4393
US

V. Phone/Fax

Practice location:
  • Phone: 501-227-9080
  • Fax: 501-227-0410
Mailing address:
  • Phone: 501-227-9080
  • Fax: 501-227-0410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberE-20990
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberE-20990
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: