Healthcare Provider Details

I. General information

NPI: 1477713055
Provider Name (Legal Business Name): DAVID A BREITENFELD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 OLD DES PERES RD
DES PERES MO
63131-1865
US

IV. Provider business mailing address

13523 BARRETT PARKWAY DR STE 210
BALLWIN MO
62031-3802
US

V. Phone/Fax

Practice location:
  • Phone: 314-775-2264
  • Fax:
Mailing address:
  • Phone: 314-775-2816
  • Fax: 314-775-2821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number137136
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: