Provider Demographics
NPI:1629639695
Name:RABURN, NICHOLAS (CRNA)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:RABURN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:NICHOLAS
Other - Middle Name:
Other - Last Name:RABURN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:325 BUCK RD
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-2217
Mailing Address - Country:US
Mailing Address - Phone:618-406-7344
Mailing Address - Fax:
Practice Address - Street 1:4500 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5360
Practice Address - Country:US
Practice Address - Phone:618-233-7750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209019541367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered