Basic Information
| Provider Information | |||||||||
| NPI: | 1124071113 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRANNON | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 W NURSERY ST | ||||||||
| Address2: | |||||||||
| City: | BUTLER | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647301840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6602007000 | ||||||||
| FaxNumber: | 6602007015 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 W NURSERY ST | ||||||||
| Address2: | |||||||||
| City: | BUTLER | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647301840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6602007000 | ||||||||
| FaxNumber: | 6602007015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 06/03/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 148622 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 919038307 | 05 | MO | MEDICAID | 912724317 | 05 | MO | MEDICAID |