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General NPI Number Information
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NPI Number | 1700881778
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Entity Type | Individual
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Provider Name | RUSSELL T BEAVERS CRNA
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Gender | Male
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Dates
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Enumeration Date | 06/16/2005
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Last Update Date | 04/29/2016
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Provider Practice Location Address
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Address Line | 24 GLASGOW CT
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City | LITTLE ROCK
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State | AR
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Zip | 72211-2170
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Country | US
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Telephone | 870-489-1592
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Fax |
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Provider Business Mailing Address
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Address Line | 24 GLASGOW CT
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City | LITTLE ROCK
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State | AR
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Zip | 72211-2170
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Country | US
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Telephone | 870-489-1592
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | C00338
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License Number State | AR
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