Healthcare Provider Details

I. General information

NPI: 1528011558
Provider Name (Legal Business Name): BRIAN BULLARD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06030-0001
US

IV. Provider business mailing address

99 EAST RIVER DRIVE 5TH FLOOR
EAST CT
06108-7301
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-3600
  • Fax:
Mailing address:
  • Phone: 860-679-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number000092
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: