Healthcare Provider Details

I. General information

NPI: 1659511970
Provider Name (Legal Business Name): BENJAMIN WADE BRUESTLE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2009
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 BLANCA AVE
ALAMOSA CO
81101-2340
US

IV. Provider business mailing address

3340 E GOLDSTONE DR
MERIDIAN ID
83642-1026
US

V. Phone/Fax

Practice location:
  • Phone: 719-589-2511
  • Fax: 719-587-1371
Mailing address:
  • Phone: 208-302-9342
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number10005021
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number004000
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: