Basic Information
| Provider Information | |||||||||
| NPI: | 1720132343 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRANNAN | ||||||||
| FirstName: | M. | ||||||||
| MiddleName: | DOUGLAS | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4140 W 190TH ST | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905045513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102314474 | ||||||||
| FaxNumber: | 3104230387 | ||||||||
| Practice Location | |||||||||
| Address1: | 8700 BEVERLY BLVD # SB-290 | ||||||||
| Address2: | |||||||||
| City: | WEST HOLLYWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900481804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104231447 | ||||||||
| FaxNumber: | 3104230387 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 76225 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 363LA2200X | AP30005884 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 367500000X | AP30005884 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 0217761 | 01 | WA | L&I PIN | OTHER | 64963U | 01 | WA | REGENCE BLUE SHIELD PIN | OTHER | 9632712 | 05 | WA | MEDICAID | 9653106 | 05 | WA | MEDICAID |