Provider Demographics
NPI:1417250127
Name:WALTERS, BRIAN RICHARD (CRNA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:RICHARD
Last Name:WALTERS
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 1:100 E LIBERTY ST STE 800
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1428
Mailing Address - Country:US
Mailing Address - Phone:502-587-4404
Mailing Address - Fax:502-587-4156
Practice Address - Street 1:200 ABRAHAM FLEXNER WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-2877
Practice Address - Country:US
Practice Address - Phone:502-587-4404
Practice Address - Fax:502-587-4156
Is Sole Proprietor?:No
Enumeration Date:2010-12-20
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1109819163W00000X
KY3006800367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201011870AMedicaid
KY7100149750Medicaid
KYP400036170Medicare Oscar/Certification
KYP00957726Medicare PIN