Healthcare Provider Details

I. General information

NPI: 1720084080
Provider Name (Legal Business Name): BRUCE A WEINER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7171 N DALE MABRY HWY
TAMPA FL
33614-2630
US

IV. Provider business mailing address

1239 E MAIN ST
CARBONDALE IL
62901-3175
US

V. Phone/Fax

Practice location:
  • Phone: 813-558-8070
  • Fax:
Mailing address:
  • Phone: 618-457-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2133502
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209020770
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: