1770560518 NPI number — MR. BRADLEY WIERDA CRNA

Table of content: MR. BRADLEY WIERDA CRNA (NPI 1770560518)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770560518 NPI number — MR. BRADLEY WIERDA CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIERDA
Provider First Name:
BRADLEY
Provider Middle Name:
Provider Name Prefix Text:
MR.
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:
1770560518
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 507
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOWELL
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72745-0507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-647-4100
Provider Business Mailing Address Fax Number:
913-647-4120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2710 RIFE MEDICAL LANE
Provider Second Line Business Practice Location Address:
ANESTHESIA DEPT
Provider Business Practice Location Address City Name:
ROGERS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72758-1452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-338-8000
Provider Business Practice Location Address Fax Number:
479-338-3056
Provider Enumeration Date:
12/22/2005

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:  C02770 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1770560518 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 179913001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200347410A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5V232 . This is a "BCBSAR" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: P00755473 . This is a "RR" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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