Provider Demographics
NPI:1942318183
Name:BRICAULT, ROGER J (CRNA)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:J
Last Name:BRICAULT
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 3130
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34478-3130
Mailing Address - Country:US
Mailing Address - Phone:352-867-8311
Mailing Address - Fax:352-867-1053
Practice Address - Street 1:1000 WATERMAN WAY
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5266
Practice Address - Country:US
Practice Address - Phone:352-253-3333
Practice Address - Fax:352-589-3487
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP556152367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL034254800Medicaid
FLG0576OtherBC BS
FLG0576WMedicare PIN
FLG0576OtherBC BS