=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154816098
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. MATTHEW BRISTER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2018
-----------------------------------------------------
Last Update Date | 07/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1555 EXCHANGE AVE
-----------------------------------------------------
City | CONWAY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72032-7824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-793-4603
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 45 PERSIMMON RIDGE DR
-----------------------------------------------------
City | GREENBRIER
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72058-8818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-549-5044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 124193
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | AP137814
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------