Healthcare Provider Details

I. General information

NPI: 1245290873
Provider Name (Legal Business Name): MONTE CLAYTON MOORE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 08/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 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: 913-381-5200
  • Fax: 913-381-0979
Mailing address:
  • Phone: 913-381-5200
  • Fax: 913-381-0979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCO1474
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: