1467678003 NPI number — KENNETH M KIRSNER CRNA

Table of content: KENNETH M KIRSNER CRNA (NPI 1467678003)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467678003 NPI number — KENNETH M KIRSNER CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIRSNER
Provider First Name:
KENNETH
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467678003
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40731 N 3RD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85086-8932
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-848-2098
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40731 N 3RD AVE
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85086-8932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-848-2098
Provider Business Practice Location Address Fax Number:
239-939-0151
Provider Enumeration Date:
04/18/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  9242983 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: AP104135 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: CRNA-01432 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 14316 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 337141 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: CRNA1079 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: G4242 . This is a "BSFL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 308344600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".