Provider Demographics
NPI:1083642888
Name:MCNULTY, BRUCE E
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:E
Last Name:MCNULTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 COURT ST
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210-2921
Mailing Address - Country:US
Mailing Address - Phone:276-676-7000
Mailing Address - Fax:276-676-9366
Practice Address - Street 1:351 COURT ST
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-2921
Practice Address - Country:US
Practice Address - Phone:276-676-7000
Practice Address - Fax:276-676-9366
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN70535367500000X
VA0024167993367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered