Healthcare Provider Details

I. General information

NPI: 1033129713
Provider Name (Legal Business Name): SHANE HIGGINBOTHAM MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 05/06/2021
Certification Date: 05/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 SCHNEIDER DR SUITE 104
MALVERN AR
72104-4816
US

IV. Provider business mailing address

1002 SCHNEIDER DR SUITE 104
MALVERN AR
72104-4816
US

V. Phone/Fax

Practice location:
  • Phone: 501-332-7981
  • Fax: 501-337-9964
Mailing address:
  • Phone: 501-332-7981
  • Fax: 501-337-9964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA251
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE0968
License Number StateAR

VIII. Authorized Official

Name: KIM OVERTON
Title or Position: OFFICE MANAGER
Credential:
Phone: 501-337-9994