Healthcare Provider Details

I. General information

NPI: 1609032481
Provider Name (Legal Business Name): BRANDON DONALD BRYAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2008
Last Update Date: 07/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E VAUGHN AVE
RUSTON LA
71270-5950
US

IV. Provider business mailing address

135 CREEKS XING
RUSTON LA
71270-1764
US

V. Phone/Fax

Practice location:
  • Phone: 318-294-1187
  • Fax:
Mailing address:
  • Phone: 318-294-1187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN107925 AP05353
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: