=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194306456
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW COLEMAN CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2021
-----------------------------------------------------
Last Update Date | 11/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 929 N ST FRANCIS ST
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67214-3821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-268-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 241 S JAMESTOWN CIR
-----------------------------------------------------
City | ANDOVER
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67002-8814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-304-7300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 13136799062
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 557935
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------