Basic Information
Provider Information | |||||||||
NPI: | 1295726065 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BAUER | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | VINYARD | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 13523 BARRETT PARKWAY DR | ||||||||
Address2: | SUITE 210 | ||||||||
City: | BALLWIN | ||||||||
State: | MO | ||||||||
PostalCode: | 630213802 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3147752816 | ||||||||
FaxNumber: | 3147752821 | ||||||||
Practice Location | |||||||||
Address1: | 6800 STATE ROUTE 162 | ||||||||
Address2: |   | ||||||||
City: | MARYVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 620628500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4694373564 | ||||||||
FaxNumber: | 4698256903 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/02/2005 | ||||||||
LastUpdateDate: | 06/16/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/16/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 138106 | MO | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | 209006631 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 918810607 | 05 | MO |   | MEDICAID | P00298433 | 01 | MO | RR MEDICARE | OTHER | P01410773 | 01 | IL | RR MEDICARE | OTHER | 1295726065 | 05 | IL |   | MEDICAID |