Provider Demographics
NPI:1871646893
Name:BOUNSALL, JEFFREY DEAN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:DEAN
Last Name:BOUNSALL
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 1:27545 FRANKLIN RD APT 107
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-8249
Mailing Address - Country:US
Mailing Address - Phone:248-350-2718
Mailing Address - Fax:
Practice Address - Street 1:27545 FRANKLIN RD APT 107
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-8249
Practice Address - Country:US
Practice Address - Phone:248-350-2718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI077154367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704242898OtherRN LICENSE NUMBER
MI077154OtherAANA LICENSE