Provider Demographics
NPI:1104055821
Name:BULLOCH, BRETT WALLACE (CRNA)
Entity type:Individual
Prefix:MR
First Name:BRETT
Middle Name:WALLACE
Last Name:BULLOCH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1698 S 1000 E
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-2271
Mailing Address - Country:US
Mailing Address - Phone:435-219-2100
Mailing Address - Fax:
Practice Address - Street 1:754 S MAIN ST STE 5
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-5519
Practice Address - Country:US
Practice Address - Phone:435-652-1445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-02
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4928514-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered