=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407267859
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW BATEMAN CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2014
-----------------------------------------------------
Last Update Date | 05/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 TOWSON AVE
-----------------------------------------------------
City | FORT SMITH
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72901-4921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-441-4190
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2508 HIGHWAY 284
-----------------------------------------------------
City | WYNNE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72396-8478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-318-4879
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | R82315
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------