Basic Information
| Provider Information | |||||||||
| NPI: | 1356626980 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOMBERGER | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 679 CREEKSIDE WAY | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833014706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4353138678 | ||||||||
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| Practice Location | |||||||||
| Address1: | 801 POLE LINE RD W | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833015810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088141000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2011 | ||||||||
| LastUpdateDate: | 10/14/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | N-42963 | ID | N | Nursing Service Providers | Registered Nurse | 367500000X | RNA-813A | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.