=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821367863
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRUCE BALLARD CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2011
-----------------------------------------------------
Last Update Date | 12/20/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4100 INTERNATIONAL PLZ SUITE 600
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76109-4820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-529-1157
-----------------------------------------------------
Fax | 817-877-0350
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4100 INTERNATIONAL PLZ SUITE 600
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76109-4820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-529-1157
-----------------------------------------------------
Fax | 817-877-0350
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 706059
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------