Healthcare Provider Details

I. General information

NPI: 1194306456
Provider Name (Legal Business Name): MATTHEW COLEMAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 N ST FRANCIS ST
WICHITA KS
67214-3821
US

IV. Provider business mailing address

241 S JAMESTOWN CIR
ANDOVER KS
67002-8814
US

V. Phone/Fax

Practice location:
  • Phone: 316-268-5000
  • Fax:
Mailing address:
  • Phone: 316-304-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number557935
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number13136799062
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: