Provider Demographics
NPI:1326273830
Name:DORE', BLAINE C (CRNA)
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:C
Last Name:DORE'
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4377
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72503-4377
Mailing Address - Country:US
Mailing Address - Phone:870-262-3280
Mailing Address - Fax:870-262-3284
Practice Address - Street 1:1710 HARRISON ST
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-7303
Practice Address - Country:US
Practice Address - Phone:870-262-3280
Practice Address - Fax:870-262-3284
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARCTP000105367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARCTP-000105OtherTEMPORARY CRNA LICENSE