Basic Information
Provider Information | |||||||||
NPI: | 1760750368 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLOOMFIELD | ||||||||
FirstName: | DARIN | ||||||||
MiddleName: | WESLEY | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA, MHS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 755 BIRCH DR | ||||||||
Address2: |   | ||||||||
City: | DELTA | ||||||||
State: | UT | ||||||||
PostalCode: | 846248944 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8013913810 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 126 WHITE SAGE AVE | ||||||||
Address2: |   | ||||||||
City: | DELTA | ||||||||
State: | UT | ||||||||
PostalCode: | 846248937 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4358645591 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/09/2011 | ||||||||
LastUpdateDate: | 01/24/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 6800670-4406 | UT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 163W00000X | 6800670-3102 | UT | N |   | Nursing Service Providers | Registered Nurse |   |
No ID Information.