Healthcare Provider Details

I. General information

NPI: 1750771564
Provider Name (Legal Business Name): JOSHUA MATTHEW BALES CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2015
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 COTTAGE DR
LITTLE ROCK AR
72205-5400
US

IV. Provider business mailing address

4301 W MARKHAM ST # 783
LITTLE ROCK AR
72205-7101
US

V. Phone/Fax

Practice location:
  • Phone: 501-686-8118
  • Fax: 501-526-7217
Mailing address:
  • Phone: 501-686-8000
  • Fax: 501-526-5148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN0000163536
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number19957
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number228292
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: