Healthcare Provider Details

I. General information

NPI: 1629027818
Provider Name (Legal Business Name): AUTUMN ROAD FAMILY PRACTICE, P.A,
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 AUTUMN RD SUITE 200
LITTLE ROCK AR
72211-3737
US

IV. Provider business mailing address

904 AUTUMN RD SUITE 200
LITTLE ROCK AR
72211-3737
US

V. Phone/Fax

Practice location:
  • Phone: 501-227-6363
  • Fax: 501-227-8629
Mailing address:
  • Phone: 501-227-6363
  • Fax: 501-227-8629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberMC0079
License Number StateAR

VIII. Authorized Official

Name: DAWN DRENNAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 501-626-7515