Healthcare Provider Details

I. General information

NPI: 1558460295
Provider Name (Legal Business Name): DONOVAN SCOTT WILLIS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MERCY WAY
JOPLIN MO
64804-4524
US

IV. Provider business mailing address

PO BOX 11405
FORT SMITH AR
72917-1405
US

V. Phone/Fax

Practice location:
  • Phone: 417-781-2727
  • Fax:
Mailing address:
  • Phone: 479-785-2555
  • Fax: 479-785-3555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2015043775
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC01497
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: