Healthcare Provider Details

I. General information

NPI: 1265997985
Provider Name (Legal Business Name): PAUL WENDELL NICHOLSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2019
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 CANYON CREST DR
TWIN FALLS ID
83301-5934
US

IV. Provider business mailing address

201 CANYON CREST DR STE 100
TWIN FALLS ID
83301-5935
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number8752157-4406
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number69350
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: