Provider Demographics
NPI:1801146451
Name:DERSHEM, BRAD (CRNA)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:DERSHEM
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 1:398 COLUMBUS AVE
Mailing Address - Street 2:PMB79
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-6008
Mailing Address - Country:US
Mailing Address - Phone:773-288-9440
Mailing Address - Fax:
Practice Address - Street 1:540 MASSACHUSETTS AVE
Practice Address - Street 2:APT 1
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-1402
Practice Address - Country:US
Practice Address - Phone:773-288-9440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-11
Last Update Date:2021-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2283514367500000X
WI192547-30367500000X
NY654839367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered