Provider Demographics
NPI:1073625539
Name:PERSINGER, BRADLEY S (CRNA)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:S
Last Name:PERSINGER
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 1:80 ROCKCREST DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-2327
Mailing Address - Country:US
Mailing Address - Phone:304-542-3927
Mailing Address - Fax:304-768-2468
Practice Address - Street 1:80 ROCKCREST DR
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-2327
Practice Address - Country:US
Practice Address - Phone:304-542-3927
Practice Address - Fax:304-768-2468
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV48580367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2604261000Medicaid
WV27-3419445OtherTAX ID
WV8238116Medicare PIN
WV27-3419445OtherTAX ID