Basic Information
| Provider Information | |||||||||
| NPI: | 1427008176 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SKIDMORE | ||||||||
| FirstName: | TAMMY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4107 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832054107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082327760 | ||||||||
| FaxNumber: | 2082321950 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 HOSPITAL WAY | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832015175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082391000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 11/01/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | N27623 | ID | N | Nursing Service Providers | Registered Nurse | 367500000X | RNA-582 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 806817800 | 05 | ID | MEDICAID | 145477 | 01 | KS | BCBS KS GROUP 110017 | OTHER | 200429720A | 05 | KS | MEDICAID |