Basic Information
| Provider Information | |||||||||
| NPI: | 1285677278 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZEITZ | ||||||||
| FirstName: | LOREN | ||||||||
| MiddleName: | KEN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 JACOBS GULCH | ||||||||
| Address2: | |||||||||
| City: | KELLOGG | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087841221 | ||||||||
| FaxNumber: | 2087867019 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 JACOBS GULCH | ||||||||
| Address2: | |||||||||
| City: | KELLOGG | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087841221 | ||||||||
| FaxNumber: | 2087861019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 06/14/2011 | ||||||||
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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 | 207L00000X | RNA68 | ID | N | Allopathic & Osteopathic Physicians | Anesthesiology | 367500000X | N-10526 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | N-10526 | 01 | ID | IDAHO LICENSE | OTHER | 8040130300 | 05 | ID | MEDICAID |