Provider Demographics
NPI:1912903790
Name:BUCOL, BRENDA K (CRNA)
Entity type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:K
Last Name:BUCOL
Suffix:
Gender:F
Credentials:CRNA
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8054
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-996-8685
Mailing Address - Fax:314-996-8479
Practice Address - Street 1:12634 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6337
Practice Address - Country:US
Practice Address - Phone:314-996-8685
Practice Address - Fax:314-996-8479
Is Sole Proprietor?:No
Enumeration Date:2005-06-25
Last Update Date:2018-01-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO091383367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO912796612Medicaid
ILENROLLEDMedicaid
IL$$$$$$$$$003Medicaid
MO827470042Medicare PIN