Provider Demographics
NPI:1790820710
Name:BROADWATER, BRUCE E (CRNA)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:E
Last Name:BROADWATER
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 1:10861 WESTERNPORT ROAD
Mailing Address - Street 2:
Mailing Address - City:FROSTBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21532
Mailing Address - Country:US
Mailing Address - Phone:301-463-2490
Mailing Address - Fax:
Practice Address - Street 1:924 SETON DR
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-1851
Practice Address - Country:US
Practice Address - Phone:301-724-0967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR085498163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR085498OtherMD STATE BD OF NURS