Provider Demographics
NPI:1477437283
Name:GROGAN, RILEY CARLTON WADE
Entity type:Individual
Prefix:
First Name:RILEY
Middle Name:CARLTON WADE
Last Name:GROGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4196 HIGHWAY 62 412 STE A
Mailing Address - Street 2:
Mailing Address - City:HARDY
Mailing Address - State:AR
Mailing Address - Zip Code:72542-8002
Mailing Address - Country:US
Mailing Address - Phone:870-856-2100
Mailing Address - Fax:
Practice Address - Street 1:104 W STATE ST
Practice Address - Street 2:
Practice Address - City:CARAWAY
Practice Address - State:AR
Practice Address - Zip Code:72419-8553
Practice Address - Country:US
Practice Address - Phone:870-956-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-04
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR232785363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner