Provider Demographics
NPI:1851751432
Name:BULL, KEITH MAXWELL (CRNA)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:MAXWELL
Last Name:BULL
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 1:1515 E 20TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-9039
Mailing Address - Country:US
Mailing Address - Phone:505-326-6400
Mailing Address - Fax:505-326-4606
Practice Address - Street 1:2300 E 30TH ST
Practice Address - Street 2:BUILDING A
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8990
Practice Address - Country:US
Practice Address - Phone:505-326-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-25
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE101335367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ140943Medicaid
NM55278710Medicaid
NM505153YTR2Medicare PIN