Healthcare Provider Details

I. General information

NPI: 1508871443
Provider Name (Legal Business Name): GAVIN VANCE BRUNEY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 11/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 JIMMY JOHNSON BLVD
PORT ARTHUR TX
77640-2007
US

IV. Provider business mailing address

PO BOX 3084
LAKE CHARLES LA
70602-3084
US

V. Phone/Fax

Practice location:
  • Phone: 409-853-5972
  • Fax: 337-433-9861
Mailing address:
  • Phone: 409-853-5972
  • Fax: 337-433-9861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number520928
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: