Healthcare Provider Details

I. General information

NPI: 1376713008
Provider Name (Legal Business Name): BRUCE DEMKO CRNA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 01/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30544 HIGHWAY 200
PONDERAY ID
83852-5005
US

IV. Provider business mailing address

PO BOX 591
SAGLE ID
83860
US

V. Phone/Fax

Practice location:
  • Phone: 208-255-8013
  • Fax:
Mailing address:
  • Phone: 208-265-3534
  • Fax: 208-265-3534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA491A
License Number StateID

VIII. Authorized Official

Name: BRUCE DEMKO
Title or Position: SELF OWNER
Credential: CRNA
Phone: 208-255-8013