Healthcare Provider Details

I. General information

NPI: 1255541165
Provider Name (Legal Business Name): ROGER DEAN FALTYS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 09/27/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 N WESTWOOD BLVD
POPLAR BLUFF MO
63901-3396
US

IV. Provider business mailing address

3319 FOXWOOD CT
POPLAR BLUFF MO
63901-9697
US

V. Phone/Fax

Practice location:
  • Phone: 573-727-2295
  • Fax:
Mailing address:
  • Phone: 573-778-9924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2005006645
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: