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NPI Code Detail

MEDICARE: PAUL VAN DEVENTER MD APMC

MEDICARE: PAUL VAN DEVENTER MD APMC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1332900000XNon-Pharmacy Dispensing SiteMD.025612LA

General Provider Information

NPI Number : 1104337559
Entity Type Code : Organization
Provider Name (Legal Business Name) : PAUL VAN DEVENTER MD APMC
Provider Business Mailing Address
First Line : PO BOX 3328
Second Line :
City : BENTONVILLE
State : AR
Zip : 72712
Country : US
Telephone Number : 479-636-9702
Fax Number : 877-427-2307
Provider Business Practice Location Address
First Line : 1200 PINNACLE PKWY STE 3
Second Line :
City : COVINGTON
State : LA
Zip : 70433-9169
Country : US
Telephone Number : 479-636-9702
Fax Number : 877-427-2307
Authorized Official
Title or Position : NCPDP COORDINATOR
Name : MACKENZIE HAHN
Credential :
Telephone Number : 479-636-9702
Provider Enumeration Date : 10/12/2017
Last Update Date : 11/16/2017

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