=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790100329
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDY ABBOTT FNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2014
-----------------------------------------------------
Last Update Date | 02/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1815 MOUNT TABOR RD
-----------------------------------------------------
City | CABOT
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72023-9506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-658-1451
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1815 MOUNT TABOR RD
-----------------------------------------------------
City | CABOT
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72023-9506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-658-1451
-----------------------------------------------------
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 | A003839
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------