=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811782824
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GATES ANESTHESIA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2025
-----------------------------------------------------
Last Update Date | 04/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3211 SUGAR HILL RD
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71854-9219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-772-4440
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 55990
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72215-5990
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-227-0700
-----------------------------------------------------
Fax | 501-227-0744
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JUSTIN GATES
-----------------------------------------------------
Credential | CRNA
-----------------------------------------------------
Telephone | 870-866-8646
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------