Healthcare Provider Details

I. General information

NPI: 1124174271
Provider Name (Legal Business Name): BLACK RIVER ANESTHESIA, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 MEDICAL CENTER DR
POCAHONTAS AR
72455-9436
US

IV. Provider business mailing address

PO BOX 1288
JONESBORO AR
72403-1288
US

V. Phone/Fax

Practice location:
  • Phone: 870-972-8053
  • Fax: 870-972-8053
Mailing address:
  • Phone: 870-972-8053
  • Fax: 870-972-8053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC00474 CRNA
License Number StateAR

VIII. Authorized Official

Name: SUSAN LYNN WYATT
Title or Position: OFFICE MANAGER
Credential: R.N.
Phone: 870-972-8053