Healthcare Provider Details

I. General information

NPI: 1477532430
Provider Name (Legal Business Name): DONALD FOUST CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 05/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 PHYSICIANS PARK
POPLAR BLUFF MO
63901-3956
US

IV. Provider business mailing address

14102 CHRISTY LN
POPLAR BLUFF MO
63901-9750
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-5550
  • Fax:
Mailing address:
  • Phone: 573-686-5550
  • Fax: 573-686-2139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number099888
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: