Provider Demographics
NPI:1962471748
Name:BULLARD, SUZANNE (CRNA)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:BULLARD
Suffix:
Gender:F
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:PO BOX 916
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:VA
Mailing Address - Zip Code:24236-0916
Mailing Address - Country:US
Mailing Address - Phone:276-475-3788
Mailing Address - Fax:
Practice Address - Street 1:565 RADIO HILL RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-6587
Practice Address - Country:US
Practice Address - Phone:276-782-1194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001122983367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1962471748Medicaid
VA005576S05Medicare PIN
VAP00317379Medicare PIN
VA010286W82Medicare PIN