Healthcare Provider Details

I. General information

NPI: 1669973632
Provider Name (Legal Business Name): BRIAN T PROST CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2018
Last Update Date: 04/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3237 S 16TH ST
MILWAUKEE WI
53215-4526
US

IV. Provider business mailing address

111 E WISCONSIN AVE STE 2000
MILWAUKEE WI
53202-4809
US

V. Phone/Fax

Practice location:
  • Phone: 414-290-6720
  • Fax: 414-290-6755
Mailing address:
  • Phone: 414-290-6720
  • Fax: 414-290-6755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704288432
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number8335-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: