Provider Demographics
NPI:1043288913
Name:PHIPPS, LARRY D (CRNA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:PHIPPS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9863 N SPRING VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:GRAVETTE
Mailing Address - State:AR
Mailing Address - Zip Code:72736-9735
Mailing Address - Country:US
Mailing Address - Phone:620-423-0857
Mailing Address - Fax:
Practice Address - Street 1:1400 W 4TH ST
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-3306
Practice Address - Country:US
Practice Address - Phone:620-252-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC001304367500000X
KS54086367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100246250BMedicaid
430073196OtherRAILROAD MEDICARE
OK200017590AMedicaid
KS043406OtherBCBS
OK200017590AMedicaid