Healthcare Provider Details

I. General information

NPI: 1831558360
Provider Name (Legal Business Name): IDAHO ANESTHESIA ASSOCIATES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2016
Last Update Date: 02/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 CORONADO ST
IDAHO FALLS ID
83404-7407
US

IV. Provider business mailing address

PO BOX 3424
IDAHO FALLS ID
83403-3424
US

V. Phone/Fax

Practice location:
  • Phone: 208-557-2700
  • Fax:
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 Number
License Number State

VIII. Authorized Official

Name: MICHELLE DAWN PAYNE
Title or Position: OWNER/MANAGER
Credential:
Phone: 208-525-2090