Division of Medical Services

Division of Medical Services

Medicaid Provider Enrollment Unit
DXC Technology
P.O. Box 8105 Little Rock, AR 72203-8105 501-376-2211
In state WATS 1-800-457-4454 - Fax: 501-374-0746
PRACTITIONER IDENTIFICATION NUMBER REQUEST FORM
Please select one of the following:

Physician Assistant NV (Include a W9 for the Individual)

Non-Independent Licensed Clinician (Include license) NW

Certified Behavioral Analyst Paraprofessional BP

Practitioner Name (Please print) NPI/Taxonomy Code 1346708963/253200000X
Please select one of the following:

Physician Assistant NV (Include a W9 for the Individual)Resident NWNon-Independent Licensed Clinician (Include license) NWCertified Behavioral Analyst Paraprofessional BPQBHP NTPersonal Care Aide NT
Practitioner Name
Social Security Number
Date of Birth

MonthDayYear
Date
Physical Work Address
City
State
ZIP+4
County
Phone Number (Include area code)
Mail To Address
City
State
ZIP+4
Phone Number (Indude area code)
Individual Email Address
example@example.com
Residents Only
Place Of Residency
Effective Date of Residency

MonthDayYear
Date
Practitioner's Signature

Clear
Date

MonthDayYear
Date
Mail or Fax this completed form to: Medicaid Provider Enrollment Unit DXC Technology P.O. Box 8105 Little Rock, AR 72203-8105 Fax Number: 501-374-0746
NPI/Taxanomy Code
Should be Empty: