Provider Demographics
NPI:1861439986
Name:MCKINVEN, MONTY J (CRNA)
Entity Type:Individual
Prefix:
First Name:MONTY
Middle Name:J
Last Name:MCKINVEN
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:PO BOX 683
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51102-0683
Mailing Address - Country:US
Mailing Address - Phone:712-255-2324
Mailing Address - Fax:
Practice Address - Street 1:2720 STONE PARK BLVD
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-3734
Practice Address - Country:US
Practice Address - Phone:712-255-2324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA103002367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0123695Medicaid
IA0206532Medicaid
IA0123695Medicaid