Provider Demographics
NPI:1952383051
Name:STOFIRA, BRUCE R (CRNA)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:R
Last Name:STOFIRA
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 1:500 W VOTAW ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47371-1322
Mailing Address - Country:US
Mailing Address - Phone:260-726-7131
Mailing Address - Fax:260-726-1976
Practice Address - Street 1:500 W VOTAW ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-1322
Practice Address - Country:US
Practice Address - Phone:260-726-7131
Practice Address - Fax:260-726-1976
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28156265367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000300779OtherANTHEM BCBS
INCC0460NMedicare ID - Type UnspecifiedPROVIDER NUMBER