Healthcare Provider Details

I. General information

NPI: 1073842175
Provider Name (Legal Business Name): JEFFREY C. RUSSELL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2009
Last Update Date: 12/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9601 INTERSTATE 630 EXIT 7
LITTLE ROCK AR
72205-7202
US

IV. Provider business mailing address

11001 EXECUTIVE CENTER DR STE 200
LITTLE ROCK AR
72211-4393
US

V. Phone/Fax

Practice location:
  • Phone: 501-202-2029
  • Fax: 501-202-6316
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR72315
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: