Provider Demographics
NPI:1770586190
Name:BRAY, DENNIS D (CRNA)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:D
Last Name:BRAY
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:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:100 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-9210
Practice Address - Country:US
Practice Address - Phone:800-277-8151
Practice Address - Fax:336-841-6217
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO087809367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO919780601Medicaid
MO011060263Medicare PIN
MO919780601Medicaid
MO501080003Medicare PIN