Healthcare Provider Details

I. General information

NPI: 1235734542
Provider Name (Legal Business Name): BLAKE D. WEATHERBY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 S RIFE MEDICAL LN
ROGERS AR
72758-1452
US

IV. Provider business mailing address

PO BOX 507
LOWELL AR
72745-0507
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2026009627
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberTEMP213551
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number864477
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number213551
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: