Healthcare Provider Details

I. General information

NPI: 1538648258
Provider Name (Legal Business Name): CARSON RYAN YORK PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2018
Last Update Date: 08/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 TURNER LN
SALEM AR
72576-5600
US

IV. Provider business mailing address

PO BOX 648
SALEM AR
72576-0648
US

V. Phone/Fax

Practice location:
  • Phone: 870-895-3238
  • Fax: 870-895-3356
Mailing address:
  • Phone: 870-895-3238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: