Healthcare Provider Details

I. General information

NPI: 1174600456
Provider Name (Legal Business Name): KEVIN MICHAEL OLIVER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2203 WOODRIDGE PL
GRAND ISLAND NE
68801-7236
US

IV. Provider business mailing address

2620 W FAIDLEY AVE
GRAND ISLAND NE
68803-4205
US

V. Phone/Fax

Practice location:
  • Phone: 308-381-1914
  • Fax:
Mailing address:
  • Phone: 308-381-1914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number100089
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: