Healthcare Provider Details

I. General information

NPI: 1578968533
Provider Name (Legal Business Name): BRIAN THOMAS BSN, MS, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2014
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GENERAL ST
LAWRENCE MA
01841-2961
US

IV. Provider business mailing address

1 GENERAL ST
LAWRENCE MA
01841-2961
US

V. Phone/Fax

Practice location:
  • Phone: 213-448-4104
  • Fax:
Mailing address:
  • Phone: 213-448-4104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number105259
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: