Provider Demographics
NPI:1841561826
Name:DEPUYDT, BRAD (CRNA)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:DEPUYDT
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 1:8450 GATE PKWY W UNIT 115
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1084
Mailing Address - Country:US
Mailing Address - Phone:904-571-6354
Mailing Address - Fax:
Practice Address - Street 1:2165 HERSCHEL ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-3819
Practice Address - Country:US
Practice Address - Phone:904-387-4030
Practice Address - Fax:904-381-9808
Is Sole Proprietor?:No
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9266864367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered