Provider Demographics
NPI:1104877430
Name:BUCHANAN, CHARLENE ALTHEA (CRNA)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:ALTHEA
Last Name:BUCHANAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 COLUMBIA DR
Mailing Address - Street 2:SUITE A327
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-3508
Mailing Address - Country:US
Mailing Address - Phone:813-844-4396
Mailing Address - Fax:813-844-4972
Practice Address - Street 1:2 COLUMBIA DR
Practice Address - Street 2:SUITE A327
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3508
Practice Address - Country:US
Practice Address - Phone:813-844-4396
Practice Address - Fax:813-844-4972
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1896672367500000X
IN28162578A163W00000X
KY5227A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG3099ZOtherMEDICARE GTBA REASSIGN
IN223090AOtherMEDICARE FGTBA REASSIGN
FL304720200Medicaid
FLG3099OtherBCBS
FL300807000OtherDOL ACS (FECA)
FL7861915OtherAETNA GTBA
IN200808270Medicaid
IN360880OtherANTHEM/BCBS
IN200808270Medicaid