Provider Demographics
NPI:1871636332
Name:GIRDNER, NICHOLAS BERNARD (CRNA)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:BERNARD
Last Name:GIRDNER
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 1:751 SAPPINGTON BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:MO
Mailing Address - Zip Code:63080-2354
Mailing Address - Country:US
Mailing Address - Phone:314-607-1473
Mailing Address - Fax:
Practice Address - Street 1:211 S 3RD ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1915
Practice Address - Country:US
Practice Address - Phone:618-234-2120
Practice Address - Fax:618-641-5410
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001018420367500000X
IL209007897367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO918368408Medicaid
MO833433155Medicare PIN
MO918368408Medicaid