Provider Demographics
NPI:1922311133
Name:BULLOCH, EDWIN (CRNA)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:BULLOCH
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 1:827 W 350 S
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-2941
Mailing Address - Country:US
Mailing Address - Phone:207-659-8810
Mailing Address - Fax:
Practice Address - Street 1:150 W 100 N
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2036
Practice Address - Country:US
Practice Address - Phone:207-659-8810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAA103013367500000X
UT5419392-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered