Healthcare Provider Details

I. General information

NPI: 1346412749
Provider Name (Legal Business Name): WINSTON CLARK BRUCE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2008
Last Update Date: 04/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1022 BRISTOL TRL
EVANS GA
30809-8259
US

V. Phone/Fax

Practice location:
  • Phone: 706-723-4428
  • Fax:
Mailing address:
  • Phone: 210-381-5250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2007002508
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: