Basic Information
| Provider Information | |||||||||
| NPI: | 1275074486 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOSCOW MOUNTAIN ANESTHESIA, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 W A ST | ||||||||
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| City: | MOSCOW | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838434038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088831500 | ||||||||
| FaxNumber: | 2088827701 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 W A ST | ||||||||
| Address2: | |||||||||
| City: | MOSCOW | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838434038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088831500 | ||||||||
| FaxNumber: | 2088827701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2017 | ||||||||
| LastUpdateDate: | 04/16/2017 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2088831500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.