Basic Information
| Provider Information | |||||||||
| NPI: | 1407419278 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURKS | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | TANNER | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 W MAPLE AVE STE 503 | ||||||||
| Address2: | |||||||||
| City: | SPRINGDALE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727645376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797513722 | ||||||||
| FaxNumber: | 4797511099 | ||||||||
| Practice Location | |||||||||
| Address1: | 609 W MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGDALE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727645335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797513722 | ||||||||
| FaxNumber: | 4797511099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2019 | ||||||||
| LastUpdateDate: | 11/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R095402 | AR | N | Nursing Service Providers | Registered Nurse | 367500000X | 121151 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.