Basic Information
| Provider Information | |||||||||
| NPI: | 1790884575 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BISTRAM | ||||||||
| FirstName: | BARBARA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9200 W WISCONSIN AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148055951 | ||||||||
| FaxNumber: | 4148054870 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 TAMPA GENERAL CIR | ||||||||
| Address2: | SUITE A327 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336063571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138444396 | ||||||||
| FaxNumber: | 8138444972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 09/25/2017 | ||||||||
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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 | 208M00000X | 1757 | MN | N | Allopathic & Osteopathic Physicians | Hospitalist | 367500000X | R0901280 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | ARNP9264662 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 145974030 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 309123600 | 05 | FL | MEDICAID | 39-6105970 | 05 | WI | MEDICAID | 118435100 | 05 | MN | MEDICAID | 120G9BI | 01 | MN | BCBS | OTHER | G4533 | 01 | FL | BCBS OF FLORIDA | OTHER |