Healthcare Provider Details

I. General information

NPI: 1548528706
Provider Name (Legal Business Name): TRAVIS C BLACKHURST CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2012
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 PROSPECT DR
GLENDIVE MT
59330-1999
US

IV. Provider business mailing address

1115 SE 164TH AVE DEPT 358
VANCOUVER WA
98683-8004
US

V. Phone/Fax

Practice location:
  • Phone: 406-345-3306
  • Fax:
Mailing address:
  • Phone: 360-729-1253
  • Fax: 360-729-3185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number159520
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number201402871CRNA
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberSRA100081
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR51894
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: