Provider Demographics
NPI:1427730910
Name:BRUDERER, GAVIN (CRNA, MSNA)
Entity type:Individual
Prefix:
First Name:GAVIN
Middle Name:
Last Name:BRUDERER
Suffix:
Gender:M
Credentials:CRNA, MSNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17654 N NEWDALE AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-4819
Mailing Address - Country:US
Mailing Address - Phone:208-709-2425
Mailing Address - Fax:
Practice Address - Street 1:1717 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4802
Practice Address - Country:US
Practice Address - Phone:208-459-4641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11277587-3102163W00000X
ID57794367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty