Healthcare Provider Details

I. General information

NPI: 1700240561
Provider Name (Legal Business Name): BRADY SIBBETT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N CURTIS RD
BOISE ID
83706-1309
US

IV. Provider business mailing address

PO BOX 4268
PORTLAND OR
97208-4268
US

V. Phone/Fax

Practice location:
  • Phone: 800-516-5316
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number38204
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number202008290CRNA-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: