Provider Demographics
NPI:1659511970
Name:BRUESTLE, BENJAMIN WADE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:WADE
Last Name:BRUESTLE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
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Mailing Address - Street 1:3340 E GOLDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-9342
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:3325 POCAHONTAS RD
Practice Address - Street 2:
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814-1464
Practice Address - Country:US
Practice Address - Phone:541-523-1797
Practice Address - Fax:541-523-1799
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-26
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT004000367500000X
OR10005021367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered