Provider Demographics
NPI:1184715914
Name:BREAULT, RODERICK VICTOR (CRNA)
Entity type:Individual
Prefix:MR
First Name:RODERICK
Middle Name:VICTOR
Last Name:BREAULT
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 1:7 APACHE LN
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:RI
Mailing Address - Zip Code:02864-3501
Mailing Address - Country:US
Mailing Address - Phone:401-658-4596
Mailing Address - Fax:
Practice Address - Street 1:14 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-3003
Practice Address - Country:US
Practice Address - Phone:508-473-1190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA163347367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered