Provider Demographics
NPI:1952321879
Name:FAIR, KENT ALAN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:KENT
Middle Name:ALAN
Last Name:FAIR
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 1:1011 WILSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2743
Mailing Address - Country:US
Mailing Address - Phone:618-242-4150
Mailing Address - Fax:618-244-1696
Practice Address - Street 1:1011 WILSHIRE DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2743
Practice Address - Country:US
Practice Address - Phone:618-242-4150
Practice Address - Fax:618-244-1696
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL95809Medicare ID - Type Unspecified
ILL86351Medicare ID - Type Unspecified