Basic Information
| Provider Information | |||||||||
| NPI: | 1215652375 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7336 W COHO DR | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837095691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089214113 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2537 W STATE ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837022200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083360895 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2022 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC0200X | 44136 | ID | Y | Nursing Service Providers | Registered Nurse | Critical Care Medicine |
No ID Information.