Provider Demographics
NPI:1376713008
Name:BRUCE DEMKO CRNA INC
Entity Type:Organization
Organization Name:BRUCE DEMKO CRNA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SELF OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMKO
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:208-255-8013
Mailing Address - Street 1:PO BOX 591
Mailing Address - Street 2:
Mailing Address - City:SAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83860
Mailing Address - Country:US
Mailing Address - Phone:208-265-3534
Mailing Address - Fax:208-265-3534
Practice Address - Street 1:30544 HIGHWAY 200
Practice Address - Street 2:
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-5005
Practice Address - Country:US
Practice Address - Phone:208-255-8013
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRNA491A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1603791Medicare PIN