Provider Demographics
NPI:1700881778
Name:BEAVERS, RUSSELL T (CRNA)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:T
Last Name:BEAVERS
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 1:24 GLASGOW CT
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-2170
Mailing Address - Country:US
Mailing Address - Phone:870-489-1592
Mailing Address - Fax:
Practice Address - Street 1:24 GLASGOW CT
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-2170
Practice Address - Country:US
Practice Address - Phone:870-489-1592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC00338367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR59622OtherBCBS
430014101OtherRRMCR/PGBA
AR125085701Medicaid
AR6003788OtherTRICARE/HUMANA
AR59622OtherBCBS