Healthcare Provider Details

I. General information

NPI: 1992923718
Provider Name (Legal Business Name): SHARM R STANGER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W STATE ST
BOISE ID
83702-0001
US

IV. Provider business mailing address

111 W STATE ST
BOISE ID
83702-6127
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR1664474
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number256594
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: