Provider Demographics
NPI:1134182215
Name:HARLAN, GARY ALLEN (CRNA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:ALLEN
Last Name:HARLAN
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 1:211 SAINT FRANCIS DR
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5049
Mailing Address - Country:US
Mailing Address - Phone:573-331-3000
Mailing Address - Fax:913-341-5797
Practice Address - Street 1:211 SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5049
Practice Address - Country:US
Practice Address - Phone:573-331-3000
Practice Address - Fax:913-341-5797
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002017914367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO405586OtherBCBS
MO919026302Medicaid
MO110375OtherHEALTH LINK
MO105535OtherHEALTH ALLIANCE
MOA165OtherCHAMPUS TRICARE
MO430079551OtherRAILROAD MEDICARE
MO430079551OtherRAILROAD MEDICARE
IL$$$$$$$$$001Medicaid