Basic Information
| Provider Information | |||||||||
| NPI: | 1861512105 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REDAM | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4301 W MARKHAM ST # 783 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722057101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016868000 | ||||||||
| FaxNumber: | 5015265148 | ||||||||
| Practice Location | |||||||||
| Address1: | 4301 W MARKHAM ST # 515 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722057101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016031211 | ||||||||
| FaxNumber: | 5016867618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 11/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ATP000061 | AR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | A002998 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | A02998 | 01 | AR | LICENSE | OTHER | ATP000061 | 01 | AR | LICENSE | OTHER |