Provider Demographics
NPI:1659976751
Name:MODERN ANESTHESIA CONSULTANTS, LLC
Entity type:Organization
Organization Name:MODERN ANESTHESIA CONSULTANTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AR/CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:D
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-620-2336
Mailing Address - Street 1:PO BOX 290342
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37229-0342
Mailing Address - Country:US
Mailing Address - Phone:615-620-2320
Mailing Address - Fax:615-620-2323
Practice Address - Street 1:810 MERRIMAN ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-4436
Practice Address - Country:US
Practice Address - Phone:501-329-3937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty