Basic Information
| Provider Information | |||||||||
| NPI: | 1891745642 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUCK | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 840 | ||||||||
| Address2: | 5151 HIGHWAY 54 SUITE F | ||||||||
| City: | OSAGE BEACH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650650840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733021661 | ||||||||
| FaxNumber: | 5733021719 | ||||||||
| Practice Location | |||||||||
| Address1: | 54 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | OSAGE BEACH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650653050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733021661 | ||||||||
| FaxNumber: | 5733021719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 07/20/2010 | ||||||||
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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 | RN086549 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 912904224 | 05 | MO | MEDICAID |