Provider Demographics
NPI:1801182035
Name:RICHARDSON, BRYAN L (CRNA)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:L
Last Name:RICHARDSON
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 1:2414 N LINDBERG ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-3625
Mailing Address - Country:US
Mailing Address - Phone:314-503-2502
Mailing Address - Fax:
Practice Address - Street 1:520 S SANTA FE AVE
Practice Address - Street 2:# 260
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401-4190
Practice Address - Country:US
Practice Address - Phone:785-827-2238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-105503-122367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered