Healthcare Provider Details

I. General information

NPI: 1841223823
Provider Name (Legal Business Name): BRUCE T WREATH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N WASHINGTON ST
DU QUOIN IL
62832-1230
US

IV. Provider business mailing address

8213 NW 79TH TER
KANSAS CITY MO
64152-4206
US

V. Phone/Fax

Practice location:
  • Phone: 618-542-2146
  • Fax:
Mailing address:
  • Phone: 618-318-2350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number24046
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: