Basic Information
| Provider Information | |||||||||
| NPI: | 1649411455 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCAGGS | ||||||||
| FirstName: | KRISTA | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | KRISTA | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 620 N MAIN | ||||||||
| Address2: | |||||||||
| City: | HARRISON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726012911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704144000 | ||||||||
| FaxNumber: | 8704144961 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 N MAIN | ||||||||
| Address2: | |||||||||
| City: | HARRISON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726012911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704144000 | ||||||||
| FaxNumber: | 8704144961 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2009 | ||||||||
| LastUpdateDate: | 10/08/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 155401 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | C002966 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 771164501 | 01 | AR | BREASTCARE | OTHER | 179294001 | 05 | AR | MEDICAID |