Basic Information
| Provider Information | |||||||||
| NPI: | 1790943942 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALTER | ||||||||
| FirstName: | GAIL | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1223 COMMERCE DR STE 1 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726532617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704247070 | ||||||||
| FaxNumber: | 8704246616 | ||||||||
| Practice Location | |||||||||
| Address1: | 624 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726532955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705081000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2008 | ||||||||
| LastUpdateDate: | 07/13/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | C01537 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 175684001 | 05 | AR | MEDICAID | 771090701 | 01 | AR | BREASTCARE | OTHER | C01537 | 01 | AR | CRNA LICENSE | OTHER |