Healthcare Provider Details

I. General information

NPI: 1194281840
Provider Name (Legal Business Name): RYAN PAYNE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2019
Last Update Date: 05/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 S RIFE MEDICAL LN
ROGERS AR
72758-1452
US

IV. Provider business mailing address

2710 S RIFE MEDICAL LN
ROGERS AR
72758-1452
US

V. Phone/Fax

Practice location:
  • Phone: 479-636-0200
  • Fax: 479-986-3448
Mailing address:
  • Phone: 479-636-0200
  • Fax: 479-986-3448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA006156
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: