Healthcare Provider Details

I. General information

NPI: 1104132356
Provider Name (Legal Business Name): DOUGLAS G BUFKIN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2010
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 E ELWOOD ST STE 500
PHOENIX AZ
85040-1978
US

IV. Provider business mailing address

3181 SW SAM JACKSON PARK RD
PORTLAND OR
97239-3011
US

V. Phone/Fax

Practice location:
  • Phone: 602-200-9021
  • Fax:
Mailing address:
  • Phone: 503-494-7641
  • Fax: 503-494-8368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number201260043CRNA
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number299836
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: