Provider Demographics
NPI:1699004648
Name:UNDERWOOD, GABRIEL CHAD (CRNA)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:CHAD
Last Name:UNDERWOOD
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 507
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-0507
Mailing Address - Country:US
Mailing Address - Phone:913-642-4900
Mailing Address - Fax:913-381-0979
Practice Address - Street 1:2710 RIFE MEDICAL LN
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-1452
Practice Address - Country:US
Practice Address - Phone:913-642-4900
Practice Address - Fax:913-381-0979
Is Sole Proprietor?:No
Enumeration Date:2009-12-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC002795367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR771111701OtherBREASTCARE
AR182910001Medicaid
OK200274730AMedicaid
AR771111701OtherBREASTCARE