Provider Demographics
NPI:1457353989
Name:YEAGER, KENNETH PAUL (CRNA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:PAUL
Last Name:YEAGER
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 1:4901 GRANDE DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8965
Mailing Address - Country:US
Mailing Address - Phone:850-477-7042
Mailing Address - Fax:850-474-9060
Practice Address - Street 1:2100 N DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-9412
Practice Address - Country:US
Practice Address - Phone:573-686-5550
Practice Address - Fax:573-686-2139
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2027442367500000X
NMR61693367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM28405251Medicaid
NMP00431700OtherRAILROAD MEDICARE
AL59059908OtherBLUE CROSS & BLUE SHIELD
FLG1108OtherBLUE CROSS & BLUE SHIELD
FLG1108WMedicare ID - Type Unspecified