Basic Information
| Provider Information | |||||||||
| NPI: | 1841659315 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 607 STAGECOACH VLG | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722104773 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2710 S RIFE MEDICAL LN | ||||||||
| Address2: | |||||||||
| City: | ROGERS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727581452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4793388000 | ||||||||
| FaxNumber: | 4793383056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2016 | ||||||||
| LastUpdateDate: | 06/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R093973 | AR | N | Nursing Service Providers | Registered Nurse | 367500000X | C003142 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1D7722 | 01 | AR | BCBS ARKANSAS | OTHER | 214923001 | 05 | AR | MEDICAID | 910084593 | 05 | MO | MEDICAID |