Healthcare Provider Details

I. General information

NPI: 1023053352
Provider Name (Legal Business Name): CATHERINE LYLE MUSTAIN P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 04/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 N. MAIN STREET
MULBERRY AR
72947
US

IV. Provider business mailing address

PO BOX 130
RATCLIFF AR
72951-0130
US

V. Phone/Fax

Practice location:
  • Phone: 479-997-1484
  • Fax: 479-997-1494
Mailing address:
  • Phone: 479-635-0091
  • Fax: 479-635-2010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-279
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: