Provider Demographics
NPI:1154334043
Name:BUNBURY, RENASON (CRNA)
Entity Type:Individual
Prefix:
First Name:RENASON
Middle Name:
Last Name:BUNBURY
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 1:333 ROUTE 25A
Mailing Address - Street 2:SUITE 25A
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-8556
Mailing Address - Country:US
Mailing Address - Phone:631-744-3671
Mailing Address - Fax:631-744-6205
Practice Address - Street 1:333 ROUTE 25A
Practice Address - Street 2:SUITE 25A
Practice Address - City:ROCKY POINT
Practice Address - State:NY
Practice Address - Zip Code:11778-8556
Practice Address - Country:US
Practice Address - Phone:631-744-3671
Practice Address - Fax:631-744-6205
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY495263-1207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY495263-1OtherLICENSE