Provider Demographics
NPI:1427032499
Name:GROGAN, BRIAN DALE (CRNA)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:DALE
Last Name:GROGAN
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 1:2253 W BAY ISLE DR SE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-3350
Mailing Address - Country:US
Mailing Address - Phone:727-502-5969
Mailing Address - Fax:727-502-5968
Practice Address - Street 1:148 13TH ST SW
Practice Address - Street 2:SUITE #200
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-3127
Practice Address - Country:US
Practice Address - Phone:727-450-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP911572367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG0161OtherBCBS
FL303306600Medicaid
FLG0161OtherBCBS