Basic Information
| Provider Information | |||||||||
| NPI: | 1518915503 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRUDA | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1867 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727021867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186649892 | ||||||||
| FaxNumber: | 9186642521 | ||||||||
| Practice Location | |||||||||
| Address1: | 3215 N NORTHHILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186649892 | ||||||||
| FaxNumber: | 9186642521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 02/10/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 118708 | MO | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | E-5371 | AR | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 100317990B | 05 | MO | MEDICAID | 136770001 | 05 | AR | MEDICAID | 771081401 | 01 | AR | ARKANSAS BREASTCARE | OTHER | 203843420 | 05 | MO | MEDICAID | P00664032 | 01 | AR | RAILROAD MEDICARE | OTHER | 200126940A | 05 | OK | MEDICAID | 26178025 | 01 | MO | BCBS NUMBER | OTHER |