Basic Information
| Provider Information | |||||||||
| NPI: | 1558304329 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERMOUNTAIN ANESTHESIA, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 94289, MS 631130 | ||||||||
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| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981246589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8664870277 | ||||||||
| FaxNumber: | 7707016674 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 CHANNING WAY | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085296269 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 07/23/2019 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CRNA | ||||||||
| AuthorizedOfficialTelephone: | 8664870277 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 002712600 | 05 | ID | MEDICAID |