Healthcare Provider Details

I. General information

NPI: 1396040598
Provider Name (Legal Business Name): ROGUE ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2011
Last Update Date: 01/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 NW HAWTHORNE AVE
GRANTS PASS OR
97526-1041
US

IV. Provider business mailing address

1601 NW HAWTHORNE AVE
GRANTS PASS OR
97526-1041
US

V. Phone/Fax

Practice location:
  • Phone: 541-472-4882
  • Fax:
Mailing address:
  • Phone: 541-472-4882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number082010407CRNA
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MS. FRANCES CAROL YOUNG
Title or Position: STAFF ANESTHETIST
Credential: CRNA
Phone: 541-472-4882