Basic Information
| Provider Information | |||||||||
| NPI: | 1942343553 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDEPENDENT ANESTHESIA, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 E 17TH ST | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834046313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085252090 | ||||||||
| FaxNumber: | 2085252662 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 W BANNOCK ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837025233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083789295 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CROFT | ||||||||
| AuthorizedOfficialFirstName: | CONNIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2085252090 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RNA-246 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | A0454 | 01 | ID | BLUE CROSS | OTHER |