Provider Demographics
NPI:1316914724
Name:POOLE, GARY LEE (ANP)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:LEE
Last Name:POOLE
Suffix:
Gender:M
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:STAMPS
Mailing Address - State:AR
Mailing Address - Zip Code:71860-2816
Mailing Address - Country:US
Mailing Address - Phone:870-533-8808
Mailing Address - Fax:870-533-8838
Practice Address - Street 1:218 CHURCH ST
Practice Address - Street 2:
Practice Address - City:STAMPS
Practice Address - State:AR
Practice Address - Zip Code:71860-2816
Practice Address - Country:US
Practice Address - Phone:870-533-8808
Practice Address - Fax:870-533-8838
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01177363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARS58900Medicare UPIN
AR5U007Medicare ID - Type Unspecified