Healthcare Provider Details

I. General information

NPI: 1417937657
Provider Name (Legal Business Name): VERNON O TUCKER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2006
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3728 S PINNACLE HILLS PKWY
ROGERS AR
72758-8897
US

IV. Provider business mailing address

PO BOX 583
LOWELL AR
72745-0583
US

V. Phone/Fax

Practice location:
  • Phone: 479-790-3328
  • Fax:
Mailing address:
  • Phone: 888-991-1101
  • Fax: 903-787-5854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC000969
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: