Basic Information
| Provider Information | |||||||||
| NPI: | 1689018202 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | TRISTAN | ||||||||
| MiddleName: | BLAKE | ||||||||
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| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BENNETT | ||||||||
| OtherFirstName: | BLAKE | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 22390 | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719032390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002351415 | ||||||||
| FaxNumber: | 9132341108 | ||||||||
| Practice Location | |||||||||
| Address1: | 1910 MALVERN AVE | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719017752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013211000 | ||||||||
| FaxNumber: | 8707222421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2013 | ||||||||
| LastUpdateDate: | 12/12/2013 | ||||||||
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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 | C002981 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | CTP000234 | AR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 197567001 | 05 | AR | MEDICAID | P01230606 | 01 | AR | RR MEDICARE | OTHER |