Healthcare Provider Details

I. General information

NPI: 1780903021
Provider Name (Legal Business Name): CHARLES MATTHEW HOLLIS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2010
Last Update Date: 05/26/2010
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

247 COUNTY ROAD 738
BROOKLAND AR
72417-8522
US

V. Phone/Fax

Practice location:
  • Phone: 573-785-7721
  • Fax:
Mailing address:
  • Phone: 870-919-7311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2010014759
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: