Provider Demographics
NPI:1134482029
Name:CHURCH, BRIAN WAYNE (CRNA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:WAYNE
Last Name:CHURCH
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 1:6489 SHADEWATER DR
Mailing Address - Street 2:
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026-6248
Mailing Address - Country:US
Mailing Address - Phone:614-668-2771
Mailing Address - Fax:
Practice Address - Street 1:405 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-4720
Practice Address - Country:US
Practice Address - Phone:561-623-2021
Practice Address - Fax:865-560-7064
Is Sole Proprietor?:No
Enumeration Date:2012-06-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.13948-NA367500000X
OHRN.320250-COA1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse