Healthcare Provider Details

I. General information

NPI: 1720687031
Provider Name (Legal Business Name): PANHANDLE ANESTHESIA ASSOCIATES OF MOSCOW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2020
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S MAIN ST
MOSCOW ID
83843-3046
US

IV. Provider business mailing address

PO BOX 9911
MOSCOW ID
83843-0200
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-4511
  • Fax:
Mailing address:
  • Phone: 208-691-1901
  • 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: TRACY L BAUER
Title or Position: PRACTICE MANAGER
Credential:
Phone: 208-691-1901