Healthcare Provider Details

I. General information

NPI: 1013149798
Provider Name (Legal Business Name): MARY A LINN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2009
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 BROADWAY ST
VAN BUREN AR
72956-5830
US

IV. Provider business mailing address

620 BROADWAY ST
VAN BUREN AR
72956-5830
US

V. Phone/Fax

Practice location:
  • Phone: 479-474-5061
  • Fax: 479-922-2007
Mailing address:
  • Phone: 479-474-5061
  • Fax: 479-922-2007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA383
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: