Healthcare Provider Details

I. General information

NPI: 1609992783
Provider Name (Legal Business Name): ALBERT WILLIAM MERRITT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 12/30/2020
Certification Date: 12/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 CEDAR ST
OROFINO ID
83544-9029
US

IV. Provider business mailing address

415 6TH ST
LEWISTON ID
83501-2431
US

V. Phone/Fax

Practice location:
  • Phone: 208-476-5777
  • Fax: 208-476-5385
Mailing address:
  • Phone: 208-743-2511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA457
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA457A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: