Provider Demographics
NPI:1053182543
Name:BOONE, BRIAN (CRNA)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BOONE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 GASTON CIR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-4914
Mailing Address - Country:US
Mailing Address - Phone:270-313-3866
Mailing Address - Fax:
Practice Address - Street 1:6225 N STATE HIGHWAY 161 STE 200
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-2241
Practice Address - Country:US
Practice Address - Phone:214-687-0001
Practice Address - Fax:972-518-2100
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-12
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1156707367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty