Healthcare Provider Details

I. General information

NPI: 1427760842
Provider Name (Legal Business Name): DAVID TANNER OLIVER APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2022
Last Update Date: 12/16/2022
Certification Date: 12/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 BATESVILLE BLVD
SOUTHSIDE AR
72501-8912
US

IV. Provider business mailing address

PO BOX 2197
BATESVILLE AR
72503-2197
US

V. Phone/Fax

Practice location:
  • Phone: 870-262-2800
  • Fax: 870-262-2815
Mailing address:
  • Phone: 870-262-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number220899
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: