Healthcare Provider Details

I. General information

NPI: 1548433485
Provider Name (Legal Business Name): PKANESTHESIA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2008
Last Update Date: 04/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RT 1 BOX 53
MEMPHIS MO
63555
US

IV. Provider business mailing address

PO BOX 29504
LAS VEGAS NV
89126-9504
US

V. Phone/Fax

Practice location:
  • Phone: 660-465-8511
  • Fax: 660-465-2956
Mailing address:
  • Phone: 702-878-0070
  • Fax: 702-818-1930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number134066
License Number StateMO

VIII. Authorized Official

Name: PAUL KEMP
Title or Position: CRNA
Credential: M.D.
Phone: 702-878-0070