Healthcare Provider Details

I. General information

NPI: 1386031482
Provider Name (Legal Business Name): TRAVIS BURLEYSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2015
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10010 KENNERLY RD
SAINT LOUIS MO
63128-2106
US

IV. Provider business mailing address

PO BOX 22407
SAINT LOUIS MO
63126-0407
US

V. Phone/Fax

Practice location:
  • Phone: 636-386-7222
  • Fax: 636-200-4036
Mailing address:
  • Phone: 636-386-7222
  • Fax: 636-200-4036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2015011088
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209013797
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: