Basic Information
| Provider Information | |||||||||
| NPI: | 1922534056 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKWILL | ||||||||
| FirstName: | TRENT | ||||||||
| MiddleName: | COLIN | ||||||||
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| Credential: | CRNA, DNAP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4904 BALLENTINE ST | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662031688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7857694106 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3901 RAINBOW BLVD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 661608500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135885000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2017 | ||||||||
| LastUpdateDate: | 06/26/2017 | ||||||||
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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 | 13119182 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 43-557501-011 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.