Healthcare Provider Details

I. General information

NPI: 1063035038
Provider Name (Legal Business Name): GRANT GEBHARDT BSN, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2020
Last Update Date: 08/24/2024
Certification Date: 08/24/2024
Deactivation Date: 11/30/2020
Reactivation Date: 06/17/2024

III. Provider practice location address

3215 N NORTHHILLS BLVD
FAYETTEVILLE AR
72703-4424
US

IV. Provider business mailing address

3215 N NORTHHILLS BLVD
FAYETTEVILLE AR
72703-4424
US

V. Phone/Fax

Practice location:
  • Phone: 479-463-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR108631
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number230182
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: