Healthcare Provider Details

I. General information

NPI: 1033459938
Provider Name (Legal Business Name): GARRETT T REBEL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2013
Last Update Date: 03/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3515 BROADWAY AVE
GREAT BEND KS
67530-3633
US

IV. Provider business mailing address

PO BOX 48037
WICHITA KS
67201-8037
US

V. Phone/Fax

Practice location:
  • Phone: 800-475-6236
  • Fax:
Mailing address:
  • Phone: 800-475-6236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number557141
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: