Healthcare Provider Details

I. General information

NPI: 1326050774
Provider Name (Legal Business Name): BRUCE CRAVER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 04/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 GOLDER ST
LEWISTON ME
04240-6033
US

IV. Provider business mailing address

PO BOX 1823
LEWISTON ME
04241-1823
US

V. Phone/Fax

Practice location:
  • Phone: 207-755-3715
  • Fax: 207-755-3728
Mailing address:
  • Phone: 207-755-3715
  • Fax: 207-755-3728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR047365
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: