Basic Information
| Provider Information | |||||||||
| NPI: | 1104877430 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUCHANAN | ||||||||
| FirstName: | CHARLENE | ||||||||
| MiddleName: | ALTHEA | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 COLUMBIA DR | ||||||||
| Address2: | SUITE A327 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336063508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138444396 | ||||||||
| FaxNumber: | 8138444972 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 COLUMBIA DR | ||||||||
| Address2: | SUITE A327 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336063508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138444396 | ||||||||
| FaxNumber: | 8138444972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 04/14/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 1896672 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | 28162578A | IN | N | Nursing Service Providers | Registered Nurse | 367500000X | 5227A | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | G3099Z | 01 | FL | MEDICARE GTBA REASSIGN | OTHER | 223090A | 01 | IN | MEDICARE FGTBA REASSIGN | OTHER | 304720200 | 05 | FL | MEDICAID | G3099 | 01 | FL | BCBS | OTHER | 300807000 | 01 | FL | DOL ACS (FECA) | OTHER | 7861915 | 01 | FL | AETNA GTBA | OTHER | 200808270 | 05 | IN | MEDICAID | 360880 | 01 | IN | ANTHEM/BCBS | OTHER |