Provider Demographics
NPI:1417064197
Name:BRECKENRIDGE, DAN B (CRNA)
Entity Type:Individual
Prefix:MR
First Name:DAN
Middle Name:B
Last Name:BRECKENRIDGE
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:PO BOX 172104
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38187-2104
Mailing Address - Country:US
Mailing Address - Phone:901-682-6828
Mailing Address - Fax:901-682-9316
Practice Address - Street 1:1068 CRESTHAVEN RD
Practice Address - Street 2:SUITE 150
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-0800
Practice Address - Country:US
Practice Address - Phone:901-682-6828
Practice Address - Fax:901-682-9316
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2012-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN8777367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN11682OtherTLC
MS00116184OtherMS MEDICAID
2040503OtherUHC
TN117408OtherBETTER HEALTH
TN3028383OtherBLUE CROSS
430051283Medicare ID - Type UnspecifiedRR MEDICARE
2040503OtherUHC