Provider Demographics
NPI:1063486652
Name:JOE A WRIGHT MONTICELLO ANESTHESIA SERVICE
Entity Type:Organization
Organization Name:JOE A WRIGHT MONTICELLO ANESTHESIA SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:870-460-3552
Mailing Address - Street 1:400 EAST 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-4552
Mailing Address - Country:US
Mailing Address - Phone:952-442-9770
Mailing Address - Fax:952-442-3630
Practice Address - Street 1:778 SCOGIN DRIVE
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-5729
Practice Address - Country:US
Practice Address - Phone:870-367-2411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-13
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR32806367500000X
367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
59537OtherBLUE CROSS-AR
AR5B818OtherBLUE ADVANTAGE OF AR
AR129353702Medicaid
AR770221502OtherEDS BREASTCARE PROGRAM
AR5B818OtherBLUE CROSS OF AR
AR115534701Medicaid
59537OtherBLUE CROSS-AR
AR129353702Medicaid
AR115534701Medicaid
AR5B818Medicare ID - Type Unspecified