=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508362245
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NATHAN BECKLEY WARREN PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2018
-----------------------------------------------------
Last Update Date | 02/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 609 W MAPLE AVE
-----------------------------------------------------
City | SPRINGDALE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72764-5335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-879-2393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 CORPORATE BLVD
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70508-3870
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-893-9698
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PT2018-022
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------