Healthcare Provider Details

I. General information

NPI: 1841243474
Provider Name (Legal Business Name): WALTER JESSE TRUDO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3733 N. BUSINESS DR. SUITE 101
FAYETTEVILLE AR
72703
US

IV. Provider business mailing address

1803 SW HAYFIELD AVENUE
BENTONVILLE AR
72713
US

V. Phone/Fax

Practice location:
  • Phone: 479-443-5476
  • Fax:
Mailing address:
  • Phone: 479-659-2746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR 0090514
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: