Healthcare Provider Details

I. General information

NPI: 1316907959
Provider Name (Legal Business Name): MATTHEW DAVID HICKS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 12/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W WALNUT ST
ROGERS AR
72756-3546
US

IV. Provider business mailing address

PO BOX 507
LOWELL AR
72745-0507
US

V. Phone/Fax

Practice location:
  • Phone: 479-636-0200
  • Fax: 479-936-2912
Mailing address:
  • Phone: 816-461-8288
  • Fax: 816-461-6586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCO1400
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: