Provider Demographics
NPI:1669415477
Name:GOMEZ-BOUFFARD, NILDA C (CRNA)
Entity type:Individual
Prefix:
First Name:NILDA
Middle Name:C
Last Name:GOMEZ-BOUFFARD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6336 BEECH DALY
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-3066
Mailing Address - Country:US
Mailing Address - Phone:313-565-8517
Mailing Address - Fax:248-357-0915
Practice Address - Street 1:23901 LAHSER RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-6035
Practice Address - Country:US
Practice Address - Phone:248-357-3360
Practice Address - Fax:248-357-0915
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704082875367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANB082875OtherBCBSM NUMBER