Healthcare Provider Details

I. General information

NPI: 1861980021
Provider Name (Legal Business Name): SAMUEL ZANE REDMON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2018
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 S WALDRON RD STE 107
FORT SMITH AR
72903
US

IV. Provider business mailing address

6134 S 66TH ST APT 4
FORT SMITH AR
72903-6675
US

V. Phone/Fax

Practice location:
  • Phone: 479-452-1581
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number12419763-4406
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number121901
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: