Healthcare Provider Details

I. General information

NPI: 1871595512
Provider Name (Legal Business Name): MICHAEL SCOTT FORTNER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 12/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 NEW CASTLE RD
FORREST CITY AR
72335-2218
US

IV. Provider business mailing address

PO BOX 771522
MEMPHIS TN
38177-1522
US

V. Phone/Fax

Practice location:
  • Phone: 870-261-0513
  • Fax: 901-261-2542
Mailing address:
  • Phone: 901-249-7668
  • Fax: 901-261-2542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR105201
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC002946
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: