Basic Information
| Provider Information | |||||||||
| NPI: | 1366510448 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REDMAN | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2580 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658012580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178294620 | ||||||||
| FaxNumber: | 4178294316 | ||||||||
| Practice Location | |||||||||
| Address1: | 1605 MARTIN SPRINGS DR | ||||||||
| Address2: | |||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654012931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175336010 | ||||||||
| FaxNumber: | 4175336173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 10/24/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2001004539 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 367500000X | 2010034566 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 431560263 | 01 | TRICARE | OTHER | 1366510448 | 05 | MO | MEDICAID | 970019029 | 01 | RAILROAD MEDICARE | OTHER |