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General NPI Number Information
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NPI Number | 1548600745
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Entity Type | Individual
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Provider Name | BRIAN LORIN BULLOCK CRNA
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Gender | Male
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Dates
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Enumeration Date | 07/02/2013
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Last Update Date | 11/15/2021
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Provider Practice Location Address
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Address Line | 415 6TH ST
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City | LEWISTON
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State | ID
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Zip | 83501-2431
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Country | US
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Telephone | 239-896-3934
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Fax |
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Provider Business Mailing Address
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Address Line | 1827 BIRCH DR
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City | LEWISTON
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State | ID
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Zip | 83501-6060
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Country | US
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Telephone | 239-896-3934
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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 | 261722
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | RNA-932A
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 6631838-4406
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License Number State | UT
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