Provider Demographics
NPI:1740758366
Name:BOHANNAN ANESTHESIA PLLC
Entity Type:Organization
Organization Name:BOHANNAN ANESTHESIA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:BOHANNAN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA, MSNA
Authorized Official - Phone:479-530-6649
Mailing Address - Street 1:12688 MILLER CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-9041
Mailing Address - Country:US
Mailing Address - Phone:479-530-6649
Mailing Address - Fax:
Practice Address - Street 1:3737 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-1839
Practice Address - Country:US
Practice Address - Phone:479-246-1751
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR771165401OtherAR BREAST CARE
MO914302906Medicaid
OK200330120Medicaid
AR163654001Medicaid