Basic Information
| Provider Information | |||||||||
| NPI: | 1518100759 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STUCKI | ||||||||
| FirstName: | SPENCER | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2936 | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834032936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085528773 | ||||||||
| FaxNumber: | 2085232025 | ||||||||
| Practice Location | |||||||||
| Address1: | 351 SW 9TH ST | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 979142639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418817000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2009 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 367500000X | 201360025CRNA | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1518100759 | 05 | ID | MEDICAID | 1518100759 | 05 | OR | MEDICAID |