Basic Information
| Provider Information | |||||||||
| NPI: | 1841223823 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WREATH | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8213 NW 79TH TER | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641524206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183182350 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 N WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | DU QUOIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628321230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185422146 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 24046 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.