Provider Demographics
NPI:1720132343
Name:BRANNAN, M. DOUGLAS (CRNA)
Entity Type:Individual
Prefix:
First Name:M.
Middle Name:DOUGLAS
Last Name:BRANNAN
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 1:4140 W 190TH ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-5513
Mailing Address - Country:US
Mailing Address - Phone:310-231-4474
Mailing Address - Fax:310-423-0387
Practice Address - Street 1:8700 BEVERLY BLVD # SB-290
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-1804
Practice Address - Country:US
Practice Address - Phone:310-423-1447
Practice Address - Fax:310-423-0387
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA76225367500000X
WAAP30005884363LA2200X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0217761OtherL&I PIN
WA64963UOtherREGENCE BLUE SHIELD PIN
WA9632712Medicaid
WA9653106Medicaid
WA9653106Medicaid
WA9632712Medicaid