Provider Demographics
NPI:1780651539
Name:DEMKO, BRUCE WILLIAM (CRNA)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:WILLIAM
Last Name:DEMKO
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:PO BOX 591
Mailing Address - Street 2:
Mailing Address - City:SAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83860
Mailing Address - Country:US
Mailing Address - Phone:208-265-3534
Mailing Address - Fax:208-265-3534
Practice Address - Street 1:30544 HIGHWAY 200
Practice Address - Street 2:
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-5005
Practice Address - Country:US
Practice Address - Phone:208-255-8013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN30209367500000X
IDRNA491A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805855300Medicaid
ID16037000Medicare ID - Type Unspecified