Healthcare Provider Details

I. General information

NPI: 1598722241
Provider Name (Legal Business Name): RICHARD CHARLES KIDWELL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 GOLF COURSE RD
ELKO NV
89801
US

IV. Provider business mailing address

PO BOX 1529
ELKO NV
89803-1529
US

V. Phone/Fax

Practice location:
  • Phone: 775-753-4700
  • Fax: 775-753-4703
Mailing address:
  • Phone: 775-738-2220
  • Fax: 775-738-3751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA000017
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: