MEDICARE: NATURAL STATE DERMATOLOGY PLLC

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
1	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1407719594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NATURAL STATE DERMATOLOGY PLLC

Provider Business Mailing Address
First Line	:	4206 PRINCE ST
Second Line	:
City	:	CONWAY
State	:	AR
Zip	:	72034-9398
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4206 PRINCE ST
Second Line	:
City	:	CONWAY
State	:	AR
Zip	:	72034-9398
Country	:	US
Telephone Number	:	870-250-0183
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	VIRGINIA MCGEE
Credential	:
Telephone Number	:	501-339-5152

Provider Enumeration Date	:	12/05/2025
Last Update Date	:	01/02/2026

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