Basic Information
| Provider Information | |||||||||
| NPI: | 1063868479 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TERRAULT | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | |||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD # SJH-2 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034947641 | ||||||||
| FaxNumber: | 5034948368 | ||||||||
| Practice Location | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034947641 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2016 | ||||||||
| LastUpdateDate: | 06/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 60656552 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 202004533 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1063868479 | 05 | WA | MEDICAID |