Provider Demographics
NPI:1720309511
Name:EDDY, DERRICK R (CRNA)
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:R
Last Name:EDDY
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:913-647-4100
Mailing Address - Fax:913-647-4120
Practice Address - Street 1:2601 GENE GEORGE BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-0845
Practice Address - Country:US
Practice Address - Phone:479-725-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC002970367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1720309511OtherTRICARE SOUTH
ARP01278937OtherRAILROAD
AR5UU07OtherBCBS ARKANSAS
AR198801001Medicaid
OK200494180AMedicaid
MO1720309511Medicaid