Provider Demographics
NPI:1972738987
Name:FORTNER, JOHN BRUCE JR (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BRUCE
Last Name:FORTNER
Suffix:JR
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 1:103 WASHINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:SENATH
Mailing Address - State:MO
Mailing Address - Zip Code:63876-9219
Mailing Address - Country:US
Mailing Address - Phone:573-738-2199
Mailing Address - Fax:
Practice Address - Street 1:1000 POLE CREEK CROSSING
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:NE
Practice Address - Zip Code:69162-2900
Practice Address - Country:US
Practice Address - Phone:308-254-5825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-19
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE101556367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered