Provider Demographics
NPI:1689018202
Name:BENNETT, TRISTAN BLAKE (CRNA)
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:BLAKE
Last Name:BENNETT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:BLAKE
Other - Middle Name:
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 22390
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71903-2390
Mailing Address - Country:US
Mailing Address - Phone:800-235-1415
Mailing Address - Fax:913-234-1108
Practice Address - Street 1:1910 MALVERN AVE
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-7752
Practice Address - Country:US
Practice Address - Phone:501-321-1000
Practice Address - Fax:870-722-2421
Is Sole Proprietor?:No
Enumeration Date:2013-04-25
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC002981367500000X
ARCTP000234367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR197567001Medicaid
ARP01230606OtherRR MEDICARE
AR279905YQ7WMedicare PIN