Healthcare Provider Details

I. General information

NPI: 1639238439
Provider Name (Legal Business Name): ANESTHESIA WEST, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2006
Last Update Date: 02/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 HILAND AVE
BURLEY ID
83318-2682
US

IV. Provider business mailing address

PO BOX 3659
IDAHO FALLS ID
83403-3659
US

V. Phone/Fax

Practice location:
  • Phone: 208-525-2090
  • Fax: 208-525-2662
Mailing address:
  • Phone: 208-525-2090
  • Fax: 208-525-2662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberN-16877
License Number StateID

VIII. Authorized Official

Name: CHRIS CHAD FUGATE
Title or Position: PRESIDENT
Credential: CRNA
Phone: 208-525-2090