Provider Demographics
NPI:1508871443
Name:BRUNEY, GAVIN VANCE (CRNA)
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:VANCE
Last Name:BRUNEY
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:PO BOX 3084
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70602-3084
Mailing Address - Country:US
Mailing Address - Phone:409-853-5972
Mailing Address - Fax:337-433-9861
Practice Address - Street 1:2555 JIMMY JOHNSON BLVD
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77640-2007
Practice Address - Country:US
Practice Address - Phone:409-853-5972
Practice Address - Fax:337-433-9861
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX520928367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX109774301Medicaid
TX85295HMedicare PIN
430057860Medicare PIN