Provider Demographics
NPI:1316158025
Name:HARRISON FAMILY PRACTICE CLINIC
Entity type:Organization
Organization Name:HARRISON FAMILY PRACTICE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF NURSE PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:H
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MAYO
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:870-741-8247
Mailing Address - Street 1:715 W SHERMAN AVE STE G
Mailing Address - Street 2:PO BOX 1597
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-2737
Mailing Address - Country:US
Mailing Address - Phone:870-741-8247
Mailing Address - Fax:870-741-3933
Practice Address - Street 1:715 W SHERMAN AVE
Practice Address - Street 2:SUITE G
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-2743
Practice Address - Country:US
Practice Address - Phone:870-741-8247
Practice Address - Fax:870-741-3933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAO1349363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARS45740Medicare UPIN
AR5U249Medicare ID - Type UnspecifiedMEDICARE PROVIDER #