Provider Demographics
NPI:1730358102
Name:MORIARTY, MICHAEL T (CRNA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:MORIARTY
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:888-991-1101
Mailing Address - Fax:903-787-5854
Practice Address - Street 1:3000 MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3217
Practice Address - Country:US
Practice Address - Phone:479-751-3722
Practice Address - Fax:479-751-1099
Is Sole Proprietor?:No
Enumeration Date:2008-02-29
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-085907367500000X
AR120862367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-47303OtherBC BS OF AL
AL1730358102Medicaid
AR236425001Medicaid