Provider Demographics
NPI:1548496714
Name:BRODDLE, BRYAN KEITH (CRNA)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:KEITH
Last Name:BRODDLE
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:PO BOX 3374
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-3374
Mailing Address - Country:US
Mailing Address - Phone:913-642-4900
Mailing Address - Fax:913-381-0979
Practice Address - Street 1:2610 N. WOODLAWN
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67220-2729
Practice Address - Country:US
Practice Address - Phone:316-685-6236
Practice Address - Fax:316-858-2793
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1379895032163W00000X
KS556905367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP00795820OtherRR MEDICARE GROUP CQ2302
KS200622590AMedicaid
KS200622590AMedicaid