Healthcare Provider Details

I. General information

NPI: 1457510877
Provider Name (Legal Business Name): ANNA MAE COWGUR CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 06/29/2020
Certification Date: 06/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 JACKSON ST SW
GRAVETTE AR
72736-9121
US

IV. Provider business mailing address

PO BOX 507
LOWELL AR
72745-0507
US

V. Phone/Fax

Practice location:
  • Phone: 479-787-5291
  • Fax: 479-344-6404
Mailing address:
  • Phone: 913-642-4900
  • Fax: 913-381-0979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC02714
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: