Provider Demographics
NPI:1902934870
Name:BAXLEY, BRYAN O (CRNA)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:O
Last Name:BAXLEY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MT. CARMEL WAY
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762
Mailing Address - Country:US
Mailing Address - Phone:620-231-6100
Mailing Address - Fax:620-231-0081
Practice Address - Street 1:1 MT. CARMEL WAY
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762
Practice Address - Country:US
Practice Address - Phone:620-232-0273
Practice Address - Fax:620-231-0081
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS55569367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200425080AMedicaid
14514Medicare PIN