Provider Demographics
NPI:1114933256
Name:MARSHALL, BRUCE EDWARD (CRNA)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:EDWARD
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 KIMEL PARK DR STE 120
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6983
Mailing Address - Country:US
Mailing Address - Phone:336-768-3212
Mailing Address - Fax:336-768-9019
Practice Address - Street 1:145 KIMEL PARK DR STE 120
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-768-3212
Practice Address - Fax:336-768-9019
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC180941367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA7163211Medicare ID - Type Unspecified