Provider Demographics
NPI:1558460295
Name:WILLIS, DONOVAN SCOTT (CRNA)
Entity Type:Individual
Prefix:MR
First Name:DONOVAN
Middle Name:SCOTT
Last Name:WILLIS
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 11405
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-1405
Mailing Address - Country:US
Mailing Address - Phone:479-785-2555
Mailing Address - Fax:479-785-3555
Practice Address - Street 1:3002 ROGERS AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-4232
Practice Address - Country:US
Practice Address - Phone:479-785-2555
Practice Address - Fax:479-785-3555
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC01497367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200053830AMedicaid
AR156956001Medicaid
AR5Y167Medicare ID - Type Unspecified