Provider Demographics
NPI:1023053352
Name:MUSTAIN, CATHERINE LYLE (PA)
Entity type:Individual
Prefix:MRS
First Name:CATHERINE
Middle Name:LYLE
Last Name:MUSTAIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:RATCLIFF
Mailing Address - State:AR
Mailing Address - Zip Code:72951-0130
Mailing Address - Country:US
Mailing Address - Phone:479-635-0091
Mailing Address - Fax:479-635-2010
Practice Address - Street 1:421 N. MAIN STREET
Practice Address - Street 2:
Practice Address - City:MULBERRY
Practice Address - State:AR
Practice Address - Zip Code:72947
Practice Address - Country:US
Practice Address - Phone:479-997-1484
Practice Address - Fax:479-997-1494
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-279363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR191340795Medicaid
AR191340795Medicaid