Healthcare Provider Details

I. General information

NPI: 1215652375
Provider Name (Legal Business Name): MICHAEL ROBERT ALLEN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2022
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2537 W STATE ST
BOISE ID
83702-2200
US

IV. Provider business mailing address

4172 S SELATIR WAY
MERIDIAN ID
83642-8489
US

V. Phone/Fax

Practice location:
  • Phone: 208-336-0895
  • Fax:
Mailing address:
  • Phone: 208-921-4113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number75374
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number44136
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: