Basic Information
| Provider Information | |||||||||
| NPI: | 1699327841 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MANA ANESTHESIA SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 292012 | ||||||||
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| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372292012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156202320 | ||||||||
| FaxNumber: | 6152504212 | ||||||||
| Practice Location | |||||||||
| Address1: | 3344 N FUTRALL DR STE 3 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795218200 | ||||||||
| FaxNumber: | 4795827310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2019 | ||||||||
| LastUpdateDate: | 10/08/2019 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4795716780 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDICAL ASSOCIATES OF NORTHWEST ARKANSAS PA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.