Healthcare Provider Details

I. General information

NPI: 1740758366
Provider Name (Legal Business Name): BOHANNAN ANESTHESIA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2018
Last Update Date: 11/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 W WALNUT ST
ROGERS AR
72756-1839
US

IV. Provider business mailing address

12688 MILLER CHURCH RD
BENTONVILLE AR
72712-9041
US

V. Phone/Fax

Practice location:
  • Phone: 479-246-1751
  • Fax:
Mailing address:
  • Phone: 479-530-6649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. HOLLY RAE BOHANNAN
Title or Position: OWNER
Credential: CRNA, MSNA
Phone: 479-530-6649