Provider Demographics
NPI:1841223823
Name:WREATH, BRUCE T (CRNA)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:T
Last Name:WREATH
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 1:8213 NW 79TH TER
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64152-4206
Mailing Address - Country:US
Mailing Address - Phone:618-318-2350
Mailing Address - Fax:
Practice Address - Street 1:900 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-1230
Practice Address - Country:US
Practice Address - Phone:618-542-2146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL24046367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered