Provider Demographics
NPI:1912948704
Name:BROOKOVER, KATHRYN MCGANNON (CRNA)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MCGANNON
Last Name:BROOKOVER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:774 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1909
Mailing Address - Country:US
Mailing Address - Phone:517-787-6440
Mailing Address - Fax:517-787-4146
Practice Address - Street 1:110 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:PA
Practice Address - Zip Code:16125-1726
Practice Address - Country:US
Practice Address - Phone:724-646-8242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN248644L367500000X
OH346435163W00000X
PA028088367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00427795OtherRAILROAD MEDICARE
PA0074980460002Medicaid
PADF2815OtherRAILROAD MEDICARE GROUP
OH2552143Medicaid
KY7100092930Medicaid
000000635855OtherANTHEM
IN200961940Medicaid
000000635855OtherANTHEM
KY7100092930Medicaid
OH8246181Medicare PIN