Basic Information
Provider Information | |||||||||
NPI: | 1538101050 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOYER | ||||||||
FirstName: | WENDI | ||||||||
MiddleName: | RENE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA MNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LIEBHART, RICHARDSON | ||||||||
OtherFirstName: | WENDI | ||||||||
OtherMiddleName: | RENE | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CRNA MNA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2003 KOOTENAI HEALTH WAY | ||||||||
Address2: |   | ||||||||
City: | COEUR D ALENE | ||||||||
State: | ID | ||||||||
PostalCode: | 838146051 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2084765777 | ||||||||
FaxNumber: | 2084765385 | ||||||||
Practice Location | |||||||||
Address1: | 301 CEDAR | ||||||||
Address2: | CLEARWATER VALLEY HOSPITAL | ||||||||
City: | OROFINO | ||||||||
State: | ID | ||||||||
PostalCode: | 83544 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2084768030 | ||||||||
FaxNumber: | 2084765385 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/11/2006 | ||||||||
LastUpdateDate: | 08/23/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/23/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | AP110148 | TX | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | RNA487A | ID | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 806104300 | 05 | ID |   | MEDICAID |