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General NPI Number Information
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NPI Number | 1063104164
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Entity Type | Organization
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Legal Business Name | STAN W BURLESON MD PA
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Dates
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Enumeration Date | 05/25/2023
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Last Update Date | 06/29/2023
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Provider Practice Location Address
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Address Line | 705 W 16TH ST
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City | DE WITT
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State | AR
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Zip | 72042-3414
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Country | US
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Telephone | 870-946-1326
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Fax | 870-946-4577
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Provider Business Mailing Address
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Address Line | PO BOX 32
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City | DE WITT
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State | AR
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Zip | 72042-0032
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Country | US
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Telephone | 870-233-2214
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Fax | 870-946-4577
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Authorized Official
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Title or Position | OWNER
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Name | DR. STANLEY WAYNE BURLESON
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Credential | MD
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Telephone | 870-946-1326
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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