Healthcare Provider Details

I. General information

NPI: 1104905447
Provider Name (Legal Business Name): ROBERT KINGHORN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 FALLS AVE W
TWIN FALLS ID
83301-3115
US

IV. Provider business mailing address

PO BOX 1657
TWIN FALLS ID
83303-1657
US

V. Phone/Fax

Practice location:
  • Phone: 208-734-7362
  • Fax: 208-733-9463
Mailing address:
  • Phone: 208-734-7362
  • Fax: 208-733-9463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberN-15840
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: