Provider Demographics
NPI:1457354557
Name:MANCHESTER, BRUCE REID (CRNA)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:REID
Last Name:MANCHESTER
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 1:3019 NW STEWART PKWY
Mailing Address - Street 2:STE 304, PMB 108
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-1612
Mailing Address - Country:US
Mailing Address - Phone:503-313-4948
Mailing Address - Fax:
Practice Address - Street 1:3019 NW STEWART PKWY
Practice Address - Street 2:STE 304, PMB 108
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1612
Practice Address - Country:US
Practice Address - Phone:503-313-4948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2010-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR075034942CRNA367500000X
VA0024166633367500000X
AZCRNA0530367500000X
CO4681367500000X
AK356367500000X
WAAP60119748367500000X
NMCRNA00761367500000X
MEAA083180367500000X
SDCR000534367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRNA0090Medicaid