Healthcare Provider Details

I. General information

NPI: 1679142582
Provider Name (Legal Business Name): CODY MICHAEL SEXTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 COMMERCE DR
MAUMELLE AR
72113-6700
US

IV. Provider business mailing address

2313 W BERRY ST
FAYETTEVILLE AR
72701-1558
US

V. Phone/Fax

Practice location:
  • Phone: 501-301-4530
  • Fax: 501-251-1165
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT4755
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: