Provider Demographics
NPI:1982000451
Name:BULLOCH, ROBERT DUSTIN (CRNA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DUSTIN
Last Name:BULLOCH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:DUSTIN
Other - Middle Name:
Other - Last Name:BULLOCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:1000 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84701-2061
Mailing Address - Country:US
Mailing Address - Phone:435-893-4100
Mailing Address - Fax:
Practice Address - Street 1:1000 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84701-2061
Practice Address - Country:US
Practice Address - Phone:435-893-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-11
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60840896367500000X
UT6573583-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2097438Medicaid