Healthcare Provider Details

I. General information

NPI: 1477592368
Provider Name (Legal Business Name): GARRY M MELTON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N WILLOW ST
HARRISON AR
72601-2994
US

IV. Provider business mailing address

PO BOX 432
MOUNTAIN HOME AR
72654-0432
US

V. Phone/Fax

Practice location:
  • Phone: 570-424-7070
  • Fax: 870-424-6616
Mailing address:
  • Phone: 870-424-7070
  • Fax: 870-424-6616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC00178
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: