Basic Information
| Provider Information | |||||||||
| NPI: | 1699834168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | IDENA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 N TUSTIN AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927053807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143471053 | ||||||||
| FaxNumber: | 7146471245 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 S ATLANTIC BLVD | ||||||||
| Address2: | |||||||||
| City: | MONTEREY PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917544716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6265709000 | ||||||||
| FaxNumber: | 6265705700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 09/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN056988 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.