Provider Demographics
NPI:1922190412
Name:DAVID, BRUCE S (CRNA)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:S
Last Name:DAVID
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:PO BOX 755
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-0755
Mailing Address - Country:US
Mailing Address - Phone:270-274-0480
Mailing Address - Fax:270-274-0482
Practice Address - Street 1:615 OLD SYMSONIA RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-5042
Practice Address - Country:US
Practice Address - Phone:270-527-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY876A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74087610Medicaid
KY74087610Medicaid
KYP400038732Medicare PIN