Healthcare Provider Details

I. General information

NPI: 1104378538
Provider Name (Legal Business Name): MATTHEW STEWART CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NORTHCREST DR
SPRINGFIELD TN
37172-3927
US

IV. Provider business mailing address

3340 PLAYERS CLUB PKWY SUITE 350
MEMPHIS TN
38125-8933
US

V. Phone/Fax

Practice location:
  • Phone: 615-384-1529
  • Fax: 615-384-1765
Mailing address:
  • Phone: 901-844-1590
  • Fax: 901-855-1592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number187385
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: