Healthcare Provider Details

I. General information

NPI: 1114396538
Provider Name (Legal Business Name): BRIAN ANDREW MAYNARD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2015
Last Update Date: 09/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 S BALLENGER HWY
FLINT MI
48532-3638
US

IV. Provider business mailing address

27789 OSMUN ST
MADISON HEIGHTS MI
48071-3337
US

V. Phone/Fax

Practice location:
  • Phone: 810-342-2000
  • Fax:
Mailing address:
  • Phone: 248-521-0887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704276074
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: