Provider Demographics
NPI:1972154185
Name:VAN DAM, KARLEE CAMPBELL (PA-S)
Entity type:Individual
Prefix:
First Name:KARLEE
Middle Name:CAMPBELL
Last Name:VAN DAM
Suffix:
Gender:F
Credentials:PA-S
Other - Prefix:
Other - First Name:KARLEE
Other - Middle Name:CAMPBELL
Other - Last Name:BRADBERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4375 N VANTAGE DR STE 305
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4984
Mailing Address - Country:US
Mailing Address - Phone:479-335-1831
Mailing Address - Fax:479-249-6958
Practice Address - Street 1:901 SE 22ND ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-4196
Practice Address - Country:US
Practice Address - Phone:479-273-7006
Practice Address - Fax:479-273-9497
Is Sole Proprietor?:No
Enumeration Date:2019-09-28
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3137363A00000X
ARPA1099363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1083646541Medicaid