Healthcare Provider Details

I. General information

NPI: 1962069807
Provider Name (Legal Business Name): STEVEN DAVID BOREN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2019
Last Update Date: 05/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 W 32ND ST
JOPLIN MO
64804-3503
US

IV. Provider business mailing address

106 N WINDWOOD
CARL JUNCTION MO
64834-9213
US

V. Phone/Fax

Practice location:
  • Phone: 417-347-1111
  • Fax:
Mailing address:
  • Phone: 417-569-7080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number123865
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: