Healthcare Provider Details

I. General information

NPI: 1609413343
Provider Name (Legal Business Name): INTERMOUNTAIN ANESTHESIA ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2019
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 WARNER DR
LEWISTON ID
83501-4441
US

IV. Provider business mailing address

PO BOX 84702
SEATTLE WA
98124-6002
US

V. Phone/Fax

Practice location:
  • Phone: 208-298-1050
  • Fax:
Mailing address:
  • Phone: 877-746-7090
  • Fax:

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: DUSTIN ELBEN
Title or Position: PRESIDENT
Credential: CRNA
Phone: 509-552-6666