Basic Information
| Provider Information | |||||||||
| NPI: | 1922190412 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVID | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 755 | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420250755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702740480 | ||||||||
| FaxNumber: | 2702740482 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 OLD SYMSONIA RD | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420255042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705274800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 11/30/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 876A | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 74087610 | 05 | KY | MEDICAID |