Provider Demographics
NPI:1972805802
Name:BUDDENBERG, BRADFORD CLINTON (CRNA)
Entity Type:Individual
Prefix:MR
First Name:BRADFORD
Middle Name:CLINTON
Last Name:BUDDENBERG
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 1:520 HAYES ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-6812
Mailing Address - Country:US
Mailing Address - Phone:304-228-5040
Mailing Address - Fax:
Practice Address - Street 1:2215 SMITH RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314-2110
Practice Address - Country:US
Practice Address - Phone:304-346-7313
Practice Address - Fax:304-744-9802
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-29
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV66365367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered