Provider Demographics
NPI:1538422290
Name:BROADBENT, NATHAN R (CRNA)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:R
Last Name:BROADBENT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2620 E BARNETT RD STE H
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8383
Mailing Address - Country:US
Mailing Address - Phone:541-789-4281
Mailing Address - Fax:541-789-5538
Practice Address - Street 1:500 SW RAMSEY AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5543
Practice Address - Country:US
Practice Address - Phone:541-472-7267
Practice Address - Fax:812-237-0182
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLRN 9299572367500000X
OR201407290CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered