Basic Information
| Provider Information | |||||||||
| NPI: | 1376747873 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRINCE | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6119 MIDTOWN AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722055313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016644532 | ||||||||
| FaxNumber: | 5016634335 | ||||||||
| Practice Location | |||||||||
| Address1: | 6119 MIDTOWN AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722055313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016644532 | ||||||||
| FaxNumber: | 5016634335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 01/25/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | CTP000049 | AR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | C002670 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | R069818 | AR | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | P00432091 | 01 | RR MEDICARE GROUP CC5970 | OTHER | 165278001 | 05 | AR | MEDICAID | 771053801 | 01 | AR | AR BREASTCARE | OTHER | 5A480 | 01 | AR | BCBS | OTHER |