=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225072614
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFERY LANE ULMER P.A.-C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2006
-----------------------------------------------------
Last Update Date | 12/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1102 CRESTWOOD CIR
-----------------------------------------------------
City | MENA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71953-5513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-394-7301
-----------------------------------------------------
Fax | 479-394-7160
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1102 CRESTWOOD CIR
-----------------------------------------------------
City | MENA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71953-5513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-394-7301
-----------------------------------------------------
Fax | 479-394-7160
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA-116
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------