Healthcare Provider Details

I. General information

NPI: 1912208554
Provider Name (Legal Business Name): MICHAEL MALOUF CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2010
Last Update Date: 10/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 S HIGHWAY 36
WESTON ID
83286-5000
US

IV. Provider business mailing address

PO BOX 2295
ASHEVILLE NC
28802-2295
US

V. Phone/Fax

Practice location:
  • Phone: 208-390-7843
  • Fax:
Mailing address:
  • Phone: 828-398-5244
  • Fax: 828-360-3080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN-1504
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number598527-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: