Provider Demographics
NPI:1205822152
Name:KUECKELHAN, GERALD LYNN (CRNA)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:LYNN
Last Name:KUECKELHAN
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 1:1445 CHRISTY DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-2853
Mailing Address - Country:US
Mailing Address - Phone:573-636-3483
Mailing Address - Fax:573-636-5315
Practice Address - Street 1:2505 MISSION DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-9508
Practice Address - Country:US
Practice Address - Phone:573-636-3483
Practice Address - Fax:573-636-3386
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO076407367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO430050775OtherRR MEDICARE
MO913912416Medicaid
MO913912416Medicaid