Provider Demographics
NPI:1548600745
Name:BULLOCK, BRIAN LORIN (CRNA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:LORIN
Last Name:BULLOCK
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 1:1827 BIRCH DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-6060
Mailing Address - Country:US
Mailing Address - Phone:239-896-3934
Mailing Address - Fax:
Practice Address - Street 1:415 6TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2431
Practice Address - Country:US
Practice Address - Phone:239-896-3934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-02
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261722367500000X
IDRNA-932A367500000X
UT6631838-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered