Basic Information
| Provider Information | |||||||||
| NPI: | 1811573173 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | OWEN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21416 STONEHAVEN CIR | ||||||||
| Address2: | |||||||||
| City: | GRETNA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680286921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016020769 | ||||||||
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| Practice Location | |||||||||
| Address1: | 501 S BURMA AVE | ||||||||
| Address2: | |||||||||
| City: | GILLETTE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 827163426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076881000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2021 | ||||||||
| LastUpdateDate: | 03/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 47207 | WY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.