Healthcare Provider Details

I. General information

NPI: 1265037741
Provider Name (Legal Business Name): BRANDON MADSEN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 8TH ST
RUPERT ID
83350-1599
US

IV. Provider business mailing address

1224 8TH ST
RUPERT ID
83350-1599
US

V. Phone/Fax

Practice location:
  • Phone: 208-436-0481
  • Fax: 208-436-6038
Mailing address:
  • Phone: 208-436-0481
  • Fax: 208-436-6038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number6382424-3102
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number47281
License Number StateWY
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number79700
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: