Healthcare Provider Details

I. General information

NPI: 1477811941
Provider Name (Legal Business Name): BRUCE LOWELL DEITSCH N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4102 PINION DR
USAF ACADEMY CO
80840-2502
US

IV. Provider business mailing address

4102 PINION DR
USAF ACADEMY CO
80840-2502
US

V. Phone/Fax

Practice location:
  • Phone: 973-600-6395
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberAPN.0990381-NP
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.0990381-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: