Provider Demographics
NPI:1912254475
Name:BROADBENT, PAUL DUSTIN (CRNA)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:DUSTIN
Last Name:BROADBENT
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 1:1248 CARPAZI CT
Mailing Address - Street 2:APT 4
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34105-4968
Mailing Address - Country:US
Mailing Address - Phone:801-830-8299
Mailing Address - Fax:
Practice Address - Street 1:2201 CIVIC CIR
Practice Address - Street 2:SUITE 503
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-1817
Practice Address - Country:US
Practice Address - Phone:800-480-1819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX817054367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered