Provider Demographics
NPI:1114909991
Name:BLUE, TERRY KEITH (CRNA)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:KEITH
Last Name:BLUE
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 1:1108 E WATERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:KS
Mailing Address - Zip Code:67002-7996
Mailing Address - Country:US
Mailing Address - Phone:316-425-8153
Mailing Address - Fax:316-425-8153
Practice Address - Street 1:1108 E WATERVIEW DR
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:KS
Practice Address - Zip Code:67002-7996
Practice Address - Country:US
Practice Address - Phone:316-425-8153
Practice Address - Fax:316-425-8153
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3243142367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100252100AMedicaid
FL430056874Medicaid
FLG2655Medicare ID - Type Unspecified
FL430056874Medicaid