Provider Demographics
NPI:1922379023
Name:MEDLIN, BOCEIFUS OMAR (CRNA)
Entity Type:Individual
Prefix:
First Name:BOCEIFUS
Middle Name:OMAR
Last Name:MEDLIN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:BO
Other - Middle Name:OMAR
Other - Last Name:MEDLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2929 E THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-8034
Mailing Address - Country:US
Mailing Address - Phone:602-470-5043
Mailing Address - Fax:
Practice Address - Street 1:13400 E. SHEA BLVD.
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85259
Practice Address - Country:US
Practice Address - Phone:480-342-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-20
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCRNA0817367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered