Healthcare Provider Details

I. General information

NPI: 1750691929
Provider Name (Legal Business Name): CASSIDY B WATERMAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2010
Last Update Date: 10/19/2023
Certification Date: 10/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 E CLARK ST SUITE G
POCATELLO ID
83201-3314
US

IV. Provider business mailing address

777 HOSPITAL WAY
POCATELLO ID
83201-5175
US

V. Phone/Fax

Practice location:
  • Phone: 208-232-7760
  • Fax: 208-232-1950
Mailing address:
  • Phone: 208-240-0735
  • Fax: 208-232-1950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA-781
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: