Basic Information
| Provider Information | |||||||||
| NPI: | 1467922468 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLOUD PEAK ANESTHESIA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1385 | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834031385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085252090 | ||||||||
| FaxNumber: | 2085238978 | ||||||||
| Practice Location | |||||||||
| Address1: | 1307 W 3RD ST STE B | ||||||||
| Address2: | |||||||||
| City: | GILLETTE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 827163343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076868283 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2018 | ||||||||
| LastUpdateDate: | 12/03/2018 | ||||||||
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| AuthorizedOfficialLastName: | HALL | ||||||||
| AuthorizedOfficialFirstName: | AARON | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3076965490 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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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.