Healthcare Provider Details

I. General information

NPI: 1841659315
Provider Name (Legal Business Name): BRANDON MICHAEL WILLIAMS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2016
Last Update Date: 06/18/2021
Certification Date: 06/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 S RIFE MEDICAL LN
ROGERS AR
72758-1452
US

IV. Provider business mailing address

607 STAGECOACH VLG
LITTLE ROCK AR
72210-4773
US

V. Phone/Fax

Practice location:
  • Phone: 479-338-8000
  • Fax: 479-338-3056
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR093973
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC003142
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: