Provider Demographics
NPI:1679533301
Name:BROCK, ROBERT C (CRNA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:C
Last Name:BROCK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 W MAPLE AVE STE 503
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-5376
Mailing Address - Country:US
Mailing Address - Phone:479-751-3722
Mailing Address - Fax:479-751-1099
Practice Address - Street 1:609 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-5335
Practice Address - Country:US
Practice Address - Phone:479-751-3722
Practice Address - Fax:479-751-1099
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARCOO156367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR771011201OtherARKANSAS BREASTCARE
OK100786670AMedicaid
AR112044001Medicaid
OK100786670AMedicaid