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NPI Code Detail

MEDICARE: MR. TERRY RAY BREWER JR. CRNA

MEDICARE: MR. TERRY RAY BREWER JR. CRNA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1163W00000XRegistered NurseR54097AR
2367500000XCertified Registered Nurse AnesthetistC02664AR

General Provider Information

NPI Number : 1043410632
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. TERRY RAY BREWER JR. CRNA
Provider Business Mailing Address
First Line : PO BOX 55990
Second Line :
City : LITTLE ROCK
State : AR
Zip : 72215-5990
Country : US
Telephone Number : 501-227-0700
Fax Number : 501-227-0744
Provider Business Practice Location Address
First Line : 3024 STADIUM BLVD
Second Line :
City : JONESBORO
State : AR
Zip : 72401-7415
Country : US
Telephone Number : 501-227-0700
Fax Number : 501-227-0744
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/20/2007
Last Update Date : 07/20/2007

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