Provider Demographics
NPI:1578522082
Name:WOODWORTH, BRYAN ANDREW (CRNA)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:ANDREW
Last Name:WOODWORTH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 NE MULBERRY
Mailing Address - Street 2:C/O SJS MEDICAL MANAGEMENT SUITE 202
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-4833
Mailing Address - Country:US
Mailing Address - Phone:816-389-4130
Mailing Address - Fax:816-389-4140
Practice Address - Street 1:19600 EAST 39TH STREET
Practice Address - Street 2:CENTERPOINT MEDICAL CENTER
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-2301
Practice Address - Country:US
Practice Address - Phone:816-698-7000
Practice Address - Fax:816-698-8165
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO149870367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO915365423Medicaid
MOP00297139OtherMEDICARE PIN RR
MOS55B158Medicare PIN
MO915365423Medicaid
MO452B158Medicare PIN
MOP00297139OtherMEDICARE PIN RR