Healthcare Provider Details

I. General information

NPI: 1861669541
Provider Name (Legal Business Name): GREGORY D MILLS PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 11/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 EAST MAIN
SWIFTON AR
72471-0000
US

IV. Provider business mailing address

PO BOX 497 623 N. 9TH STREET
AUGUSTA AR
72006-0497
US

V. Phone/Fax

Practice location:
  • Phone: 870-347-2534
  • Fax: 870-347-3492
Mailing address:
  • Phone: 870-347-3314
  • Fax: 870-347-3492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 258
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: