Provider Demographics
NPI:1528011558
Name:BULLARD, BRIAN (CRNA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BULLARD
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 1:99 EAST RIVER DRIVE
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:EAST
Mailing Address - State:CT
Mailing Address - Zip Code:06108-7301
Mailing Address - Country:US
Mailing Address - Phone:860-679-3600
Mailing Address - Fax:
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-0001
Practice Address - Country:US
Practice Address - Phone:860-679-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000092367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered