Basic Information
| Provider Information | |||||||||
| NPI: | 1679533301 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROCK | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | C | ||||||||
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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: | 03/25/2006 | ||||||||
| LastUpdateDate: | 09/23/2019 | ||||||||
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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 | COO156 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 771011201 | 01 | AR | ARKANSAS BREASTCARE | OTHER | 100786670A | 05 | OK | MEDICAID | 112044001 | 05 | AR | MEDICAID |