Healthcare Provider Details

I. General information

NPI: 1053891895
Provider Name (Legal Business Name): LAWRENCE A WEISENBACH APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2018
Last Update Date: 08/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 N VAN BUREN ST
WEINER AR
72479-9289
US

IV. Provider business mailing address

101 W MAIN ST
HARDY AR
72542-9566
US

V. Phone/Fax

Practice location:
  • Phone: 870-605-0014
  • Fax: 870-994-7488
Mailing address:
  • Phone: 573-718-2570
  • Fax: 870-856-2133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA005841
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: