Provider Demographics
NPI:1518915503
Name:BRUDA, NANCY L (MD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:L
Last Name:BRUDA
Suffix:
Gender:F
Credentials:MD
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 1867
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-1867
Mailing Address - Country:US
Mailing Address - Phone:918-664-9892
Mailing Address - Fax:918-664-2521
Practice Address - Street 1:3215 N NORTHHILLS BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4424
Practice Address - Country:US
Practice Address - Phone:918-664-9892
Practice Address - Fax:918-664-2521
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO118708207L00000X
ARE-5371207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO100317990BMedicaid
AR136770001Medicaid
AR771081401OtherARKANSAS BREASTCARE
MO203843420Medicaid
ARP00664032OtherRAILROAD MEDICARE
OK200126940AMedicaid
MO26178025OtherBCBS NUMBER
AR136770001Medicaid
MO100317990BMedicaid
AR5H081Medicare PIN
MOG75247Medicare UPIN