Provider Demographics
NPI:1700904455
Name:BAMBROUGH, DEE LEWIS (CRNA)
Entity Type:Individual
Prefix:MR
First Name:DEE
Middle Name:LEWIS
Last Name:BAMBROUGH
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 1:2180 W 800 S
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-4027
Mailing Address - Country:US
Mailing Address - Phone:435-828-3933
Mailing Address - Fax:435-781-6893
Practice Address - Street 1:151 W 200 N
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-1907
Practice Address - Country:US
Practice Address - Phone:435-789-3342
Practice Address - Fax:435-781-6893
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT192323-8901367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP2574Medicaid