Healthcare Provider Details

I. General information

NPI: 1851575476
Provider Name (Legal Business Name): MARTIN J KELLY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2007
Last Update Date: 11/07/2013
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: 913-642-4900
  • Fax: 913-381-0979
Mailing address:
  • Phone: 913-642-4900
  • Fax: 913-381-0979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC002728
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: