Healthcare Provider Details

I. General information

NPI: 1245727486
Provider Name (Legal Business Name): BETHANY ROBERTS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2018
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 WESTERN AVE
CONWAY AR
72034
US

IV. Provider business mailing address

525 WESTERN AVE
CONWAY AR
72034-4967
US

V. Phone/Fax

Practice location:
  • Phone: 501-208-3207
  • Fax:
Mailing address:
  • Phone: 501-208-3207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC003240
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: