Healthcare Provider Details

I. General information

NPI: 1417065152
Provider Name (Legal Business Name): OVERTON-STIFF PROFESSIONAL ANESTHESIA SERVICE LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 12/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6302 TALCREST
BOISE ID
83713-1207
US

IV. Provider business mailing address

PO BOX 2203
IDAHO FALLS ID
83403-2203
US

V. Phone/Fax

Practice location:
  • Phone: 208-939-3255
  • Fax:
Mailing address:
  • Phone: 208-525-2090
  • Fax: 208-523-8978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberN25778
License Number StateID

VIII. Authorized Official

Name: MARGUERITE OVERTON
Title or Position: PRESIDENT
Credential: CRNA
Phone: 208-939-3255