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General NPI Number Information
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NPI Number | 1124466701
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Entity Type | Organization
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Legal Business Name | PHOMAKAY PRIMARY CARE PA
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Dates
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Enumeration Date | 06/05/2013
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Last Update Date | 11/27/2013
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Provider Practice Location Address
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Address Line | 10301 MAYO DR
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City | BARLING
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State | AR
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Zip | 72923-1660
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Country | US
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Telephone | 479-782-5500
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Fax | 479-782-5502
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Provider Business Mailing Address
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Address Line | PO BOX 10154
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City | FORT SMITH
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State | AR
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Zip | 72917-0154
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Country | US
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Telephone | 479-782-5500
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Fax | 479-782-5502
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Authorized Official
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Title or Position | OWNER
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Name | CHANSAMONE M PHOMAKAY
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Credential | MD
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Telephone | 479-782-5500
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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 | E-6214
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License Number State | AR
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