=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154889707
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PANFILO ESTRADA-FLORES APRN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2019
-----------------------------------------------------
Last Update Date | 08/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 MEDICAL PARK DR
-----------------------------------------------------
City | BENTON
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72015-3353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-776-6000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1204 STAMFORD DR
-----------------------------------------------------
City | BENTON
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72019-0807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-308-2006
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number | A006076
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | A006076
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------