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General NPI Number Information
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NPI Number | 1346412749
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Entity Type | Individual
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Provider Name | WINSTON CLARK BRUCE CRNA
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Gender | Male
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Dates
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Enumeration Date | 03/26/2008
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Last Update Date | 04/13/2013
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Provider Practice Location Address
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Address Line | 1120 15TH ST
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City | AUGUSTA
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State | GA
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Zip | 30912-0004
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Country | US
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Telephone | 706-723-4428
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Fax |
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Provider Business Mailing Address
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Address Line | 1022 BRISTOL TRL
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City | EVANS
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State | GA
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Zip | 30809-8259
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Country | US
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Telephone | 210-381-5250
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 2007002508
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License Number State | MO
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