Healthcare Provider Details

I. General information

NPI: 1013754027
Provider Name (Legal Business Name): JUSTIN LANE ALEXANDER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2024
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2302 COLLEGE AVE
CONWAY AR
72034-6297
US

IV. Provider business mailing address

2850 PRINCE ST STE 43
CONWAY AR
72034-3600
US

V. Phone/Fax

Practice location:
  • Phone: 501-329-3831
  • Fax:
Mailing address:
  • Phone: 501-327-6665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number230353
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: