Healthcare Provider Details

I. General information

NPI: 1720625866
Provider Name (Legal Business Name): DANIEL ELMORE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2019
Last Update Date: 12/09/2019
Certification Date: 12/09/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E BANNOCK ST
BOISE ID
83712-6241
US

IV. Provider business mailing address

2537 W STATE ST STE 200
BOISE ID
83702-2200
US

V. Phone/Fax

Practice location:
  • Phone: 208-336-0985
  • Fax:
Mailing address:
  • Phone: 208-336-0985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number45355
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: