Provider Demographics
NPI:1629375977
Name:ROBERTS, BROOK H (CRNA)
Entity Type:Individual
Prefix:MR
First Name:BROOK
Middle Name:H
Last Name:ROBERTS
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 1:1008 OSA MARTIN BLVD
Mailing Address - Street 2:
Mailing Address - City:CHANUTE
Mailing Address - State:KS
Mailing Address - Zip Code:66720-1830
Mailing Address - Country:US
Mailing Address - Phone:316-833-1165
Mailing Address - Fax:
Practice Address - Street 1:629 S PLUMMER AVE
Practice Address - Street 2:
Practice Address - City:CHANUTE
Practice Address - State:KS
Practice Address - Zip Code:66720
Practice Address - Country:US
Practice Address - Phone:620-431-4000
Practice Address - Fax:620-431-7556
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-23
Last Update Date:2018-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS557008367500000X
OK111346367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicaid
MOPENDINGMedicaid