Healthcare Provider Details

I. General information

NPI: 1114524436
Provider Name (Legal Business Name): JOHN MARK BATES APRN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2020
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 SCHNEIDER DR STE 104
MALVERN AR
72104-4823
US

IV. Provider business mailing address

1002 SCHNEIDER DR STE 104
MALVERN AR
72104-4823
US

V. Phone/Fax

Practice location:
  • Phone: 501-337-9994
  • Fax:
Mailing address:
  • Phone: 501-467-4665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number212918
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: