Healthcare Provider Details

I. General information

NPI: 1144652694
Provider Name (Legal Business Name): TIMOTHY MORGAN NAYLOR CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2013
Last Update Date: 10/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 VISTA DR
POCATELLO ID
83201-4987
US

IV. Provider business mailing address

PO BOX 3750
SALT LAKE CITY UT
84110-3750
US

V. Phone/Fax

Practice location:
  • Phone: 208-478-1704
  • Fax:
Mailing address:
  • Phone: 800-880-3566
  • Fax: 770-701-6676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN626053
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: