Healthcare Provider Details

I. General information

NPI: 1326239419
Provider Name (Legal Business Name): JOHN THOMAS KEZELE III CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 05/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 N 100 E
PRESTON ID
83263-1326
US

IV. Provider business mailing address

104 N BEAR RIVER BLFS
PRESTON ID
83263-5184
US

V. Phone/Fax

Practice location:
  • Phone: 208-852-0137
  • Fax:
Mailing address:
  • Phone: 208-852-2019
  • Fax: 208-852-7173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA-366A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: