Provider Demographics
NPI:1043253560
Name:MARTIN, GERALYN (CRNA)
Entity type:Individual
Prefix:
First Name:GERALYN
Middle Name:
Last Name:MARTIN
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 1:11399 170TH ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY FALLS
Mailing Address - State:KS
Mailing Address - Zip Code:66088-4094
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4510 FREDERICK AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3238
Practice Address - Country:US
Practice Address - Phone:816-364-9992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS54483207L00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP00455330OtherRAILROAD MEDICARE
MO104325356000OtherCOMMUNITY HEALTH PLAN
KS146035OtherBLUE CROSS BLUE SHIELD KANSAS
KS8167OtherPREFERRED HEALTH SYSTEMS
MO917024705Medicaid
KS200536930AMedicaid
MO39351017OtherBLUE CROSS BLUE SHIELD KANSAS CITY
MOW49A00006Medicare PIN
KS180055001Medicare PIN
KS146035OtherBLUE CROSS BLUE SHIELD KANSAS
KSW49B00001Medicare PIN