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General NPI Number Information
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NPI Number | 1124021639
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Entity Type | Individual
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Provider Name | CHARLES PAUL SISCO M.D.
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Gender | Male
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Dates
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Enumeration Date | 05/31/2005
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Last Update Date | 07/13/2007
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Provider Practice Location Address
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Address Line | 17994 HABBERTON RD
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City | FAYETTEVILLE
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State | AR
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Zip | 72703-9117
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Country | US
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Telephone | 479-445-6550
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 65
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City | SPRINGDALE
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State | AR
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Zip | 72765-0065
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Country | US
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Telephone | 479-445-6550
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RA0201X
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Taxonomy Name | Allergy & Immunology (Internal Medicine) Physician
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License Number | C4144
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License Number State | AR
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