Basic Information
| Provider Information | |||||||||
| NPI: | 1043568892 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | JAXON | ||||||||
| MiddleName: | DEAN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4268 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972084268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033722740 | ||||||||
| FaxNumber: | 5033722754 | ||||||||
| Practice Location | |||||||||
| Address1: | 2325 CORONADO ST | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085572700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2012 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | N-36657 | ID | N | Nursing Service Providers | Registered Nurse | 367500000X | 847A | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.