Healthcare Provider Details

I. General information

NPI: 1861556656
Provider Name (Legal Business Name): TREVOR G. PICKETT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 E CHEROKEE ST
SPRINGFIELD MO
65804-2203
US

IV. Provider business mailing address

2412 W DEER TRAIL CT
NIXA MO
65714-7207
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-6371
  • Fax:
Mailing address:
  • Phone: 417-725-9666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2004014725
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: