Provider Demographics
NPI:1013961804
Name:MOORE, BRIAN LEE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:LEE
Last Name:MOORE
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 1:6615 BRIARWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-2986
Mailing Address - Country:US
Mailing Address - Phone:316-729-4474
Mailing Address - Fax:316-729-4474
Practice Address - Street 1:6615 BRIARWOOD CIR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-2986
Practice Address - Country:US
Practice Address - Phone:316-729-4474
Practice Address - Fax:316-729-4474
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS54974367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS144874OtherBLUE SHIELD