Provider Demographics
NPI:1104052158
Name:TOLLIVER, SETH THOMAS (APN, FNP-BC)
Entity type:Individual
Prefix:
First Name:SETH
Middle Name:THOMAS
Last Name:TOLLIVER
Suffix:
Gender:M
Credentials:APN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MASTER SERGEANT DAN WASSOM
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK AFB
Mailing Address - State:AR
Mailing Address - Zip Code:72099-0001
Mailing Address - Country:US
Mailing Address - Phone:501-987-5474
Mailing Address - Fax:
Practice Address - Street 1:101 MASTER SERGEANT DAN WASSOM
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK AFB
Practice Address - State:AR
Practice Address - Zip Code:72099-0001
Practice Address - Country:US
Practice Address - Phone:501-987-5474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-04
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03244 ANP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily