Provider Demographics
NPI:1477592368
Name:MELTON, GARRY M (CRNA)
Entity Type:Individual
Prefix:
First Name:GARRY
Middle Name:M
Last Name:MELTON
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 432
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654-0432
Mailing Address - Country:US
Mailing Address - Phone:870-424-7070
Mailing Address - Fax:870-424-6616
Practice Address - Street 1:620 N WILLOW ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-2994
Practice Address - Country:US
Practice Address - Phone:570-424-7070
Practice Address - Fax:870-424-6616
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC00178367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR101294701Medicaid
AR101294701Medicaid