Basic Information
| Provider Information | |||||||||
| NPI: | 1104905447 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KINGHORN | ||||||||
| FirstName: | ROBERT | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1657 | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833031657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087347362 | ||||||||
| FaxNumber: | 2087339463 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 FALLS AVE W | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833013115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087347362 | ||||||||
| FaxNumber: | 2087339463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 07/16/2014 | ||||||||
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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 | 367500000X | N-15840 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 004372800 | 05 | ID | MEDICAID |