Healthcare Provider Details

I. General information

NPI: 1689081143
Provider Name (Legal Business Name): JONATHAN BRYAN SPERRY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2014
Last Update Date: 07/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 FOUR STATES DR SUITE 1
GALENA KS
66739-4324
US

IV. Provider business mailing address

444 FOUR STATES DR SUITE 1
GALENA KS
66739-4324
US

V. Phone/Fax

Practice location:
  • Phone: 620-783-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number43-557259-051
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2014017974
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: