Provider Demographics
NPI:1710946736
Name:OGLE, SAMUEL LANCE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:LANCE
Last Name:OGLE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
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Mailing Address - Street 1:P.O. BOX 771522
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38177-1522
Mailing Address - Country:US
Mailing Address - Phone:901-747-4624
Mailing Address - Fax:901-261-2542
Practice Address - Street 1:1601 NEW CASTLE RD
Practice Address - Street 2:
Practice Address - City:FORREST CITY
Practice Address - State:AR
Practice Address - Zip Code:72335-2218
Practice Address - Country:US
Practice Address - Phone:870-261-0513
Practice Address - Fax:870-261-0535
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC00837367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR122249701Medicaid
AR5S391OtherARKANSAS BLUE CROSS BLUE SHIELD
AR1710946736OtherBAPTIST HEALTH SERVICES GROUP, INC.
AR1710946736OtherTRI-CARE - SOUTH REGION
AR122249701Medicaid