Basic Information
| Provider Information | |||||||||
| NPI: | 1407353428 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED ANESTHESIA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 CANYON RD | ||||||||
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| City: | MONTPELIER | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832541218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083907757 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1155 POCATELLO CREEK RD | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832012949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082386337 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2018 | ||||||||
| LastUpdateDate: | 04/06/2018 | ||||||||
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| AuthorizedOfficialLastName: | GRUNIG | ||||||||
| AuthorizedOfficialFirstName: | DORIAN | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2083907757 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RNA613A | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.