Provider Demographics
NPI:1972064954
Name:RUTTER, JOHN MARK (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARK
Last Name:RUTTER
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 1:2101 BOULDER CV
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-9339
Mailing Address - Country:US
Mailing Address - Phone:870-834-9777
Mailing Address - Fax:
Practice Address - Street 1:225 E JACKSON AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3119
Practice Address - Country:US
Practice Address - Phone:870-207-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-30
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR126169367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered