Healthcare Provider Details

I. General information

NPI: 1891854675
Provider Name (Legal Business Name): KEVIN B VAUGHAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 E BROADWAY
COLUMBIA MO
65201-5844
US

IV. Provider business mailing address

1316 OLD 63 S SUITE 102
COLUMBIA MO
65201-6092
US

V. Phone/Fax

Practice location:
  • Phone: 573-815-8000
  • Fax:
Mailing address:
  • Phone: 573-875-8838
  • Fax: 573-875-8589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number141056
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: