Healthcare Provider Details

I. General information

NPI: 1861934317
Provider Name (Legal Business Name): SCOTT G SPENCER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2016
Last Update Date: 10/29/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 KOOTENAI HEALTH WAY
COEUR D ALENE ID
83814-6051
US

IV. Provider business mailing address

PO BOX 35145 #40023
SEATTLE WA
98124-5145
US

V. Phone/Fax

Practice location:
  • Phone: 208-765-8585
  • Fax:
Mailing address:
  • Phone: 425-407-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP60699005
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number65561
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: