Healthcare Provider Details

I. General information

NPI: 1720335201
Provider Name (Legal Business Name): WESTOVER ANESTHESIA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2012
Last Update Date: 08/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1828 MILLENIUM WAY SUITE 100
MERIDIAN ID
83642-5036
US

IV. Provider business mailing address

PO BOX 2408
IDAHO FALLS ID
83403-2408
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-0262
  • Fax:
Mailing address:
  • Phone: 208-552-8773
  • Fax: 208-523-2025

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: SHAD B WESTOVER
Title or Position: MANAGER
Credential: CRNA
Phone: 208-549-8268