Healthcare Provider Details

I. General information

NPI: 1972763381
Provider Name (Legal Business Name): BENJAMIN GUERCIO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 8TH ST
RUPERT ID
83350-1527
US

IV. Provider business mailing address

98 RIVERSIDE DR
BURLEY ID
83318-5415
US

V. Phone/Fax

Practice location:
  • Phone: 208-436-0481
  • Fax:
Mailing address:
  • Phone: 801-300-8071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number51561064406
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberN-44886
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: