Healthcare Provider Details

I. General information

NPI: 1922436062
Provider Name (Legal Business Name): SIESTA ANESTHESIA SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N 3RD AVE
SANDPOINT ID
83864-1507
US

IV. Provider business mailing address

PO BOX 2556
SANDPOINT ID
83864-0917
US

V. Phone/Fax

Practice location:
  • Phone: 208-263-1441
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberM-12159
License Number StateID

VIII. Authorized Official

Name: MICHAEL ROSENKRANZ
Title or Position: MEMBER
Credential: M.D.
Phone: 208-610-5503