Provider Demographics
NPI:1790884575
Name:BISTRAM, BARBARA ANN (CRNA)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:ANN
Last Name:BISTRAM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-5951
Mailing Address - Fax:414-805-4870
Practice Address - Street 1:1 TAMPA GENERAL CIR
Practice Address - Street 2:SUITE A327
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3571
Practice Address - Country:US
Practice Address - Phone:813-844-4396
Practice Address - Fax:813-844-4972
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1757208M00000X
MNR0901280367500000X
FLARNP9264662367500000X
WI145974030367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL309123600Medicaid
WI39-6105970Medicaid
MN118435100Medicaid
MN120G9BIOtherBCBS
FLG4533OtherBCBS OF FLORIDA
FL309123600Medicaid
MN118435100Medicaid