Provider Demographics
NPI:1104827062
Name:BRIMMER, KORY JOHN (CRNA)
Entity Type:Individual
Prefix:
First Name:KORY
Middle Name:JOHN
Last Name:BRIMMER
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 1:2415 E YANDELL DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79903
Mailing Address - Country:US
Mailing Address - Phone:915-577-0111
Mailing Address - Fax:915-533-2568
Practice Address - Street 1:2415 E YANDELL DR
Practice Address - Street 2:SUITE B
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79903-3616
Practice Address - Country:US
Practice Address - Phone:915-577-0030
Practice Address - Fax:915-533-2568
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX699797367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX169090102Medicaid
039040OtherCOUNSIL ON RECERTIF OF NA
039040OtherCOUNSIL ON RECERTIF OF NA