Healthcare Provider Details

I. General information

NPI: 1225072614
Provider Name (Legal Business Name): JEFFERY LANE ULMER P.A.-C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 12/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 CRESTWOOD CIR
MENA AR
71953-5513
US

IV. Provider business mailing address

1102 CRESTWOOD CIR
MENA AR
71953-5513
US

V. Phone/Fax

Practice location:
  • Phone: 479-394-7301
  • Fax: 479-394-7160
Mailing address:
  • Phone: 479-394-7301
  • Fax: 479-394-7160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-116
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: