Basic Information
Provider Information | |||||||||
NPI: | 1922438233 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROGERS | ||||||||
FirstName: | RUSSELL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3075 N 3422 E | ||||||||
Address2: |   | ||||||||
City: | KIMBERLY | ||||||||
State: | ID | ||||||||
PostalCode: | 833415362 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8014587624 | ||||||||
FaxNumber: | 2087339463 | ||||||||
Practice Location | |||||||||
Address1: | 115 FALLS AVE W | ||||||||
Address2: |   | ||||||||
City: | TWIN FALLS | ||||||||
State: | ID | ||||||||
PostalCode: | 833013115 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2087331662 | ||||||||
FaxNumber: | 2087339463 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/22/2013 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | CRNA-01284 | NM | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | 55818 | ID | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
No ID Information.