Provider Demographics
NPI:1346412749
Name:BRUCE, WINSTON CLARK (CRNA)
Entity Type:Individual
Prefix:
First Name:WINSTON
Middle Name:CLARK
Last Name:BRUCE
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 1:1022 BRISTOL TRL
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-8259
Mailing Address - Country:US
Mailing Address - Phone:210-381-5250
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-723-4428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2013-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007002508367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO916364409Medicaid
MOS55000001Medicare PIN
MO916364409Medicaid
MOP00633127Medicare PIN