Provider Demographics
NPI:1457317828
Name:FAIR, TOMMY LEE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:TOMMY
Middle Name:LEE
Last Name:FAIR
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 1:200 W TYLER AVE
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-4223
Mailing Address - Country:US
Mailing Address - Phone:870-735-1500
Mailing Address - Fax:870-733-3861
Practice Address - Street 1:200 W TYLER AVE
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4223
Practice Address - Country:US
Practice Address - Phone:870-735-1500
Practice Address - Fax:870-733-3861
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12971367500000X
ARC00206367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR19795701Medicaid
AR19795701Medicaid