Healthcare Provider Details

I. General information

NPI: 1093258386
Provider Name (Legal Business Name): TRAVIS HENDERSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2016
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 ARLINGTON AVE
CALDWELL ID
83605-4802
US

IV. Provider business mailing address

6452 E SHELLBROOK DR
NAMPA ID
83687-4126
US

V. Phone/Fax

Practice location:
  • Phone: 208-459-4641
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number41135
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number112038
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: