Healthcare Provider Details

I. General information

NPI: 1043727902
Provider Name (Legal Business Name): ROBERT ERRON COOKS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2018
Last Update Date: 01/27/2020
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 E BANNOCK ST
BOISE ID
83712-6207
US

IV. Provider business mailing address

2227 E MORES TRAIL DR
MERIDIAN ID
83642-4803
US

V. Phone/Fax

Practice location:
  • Phone: 208-336-0895
  • Fax: 208-338-1796
Mailing address:
  • Phone: 801-244-6083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number57199
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: