Healthcare Provider Details

I. General information

NPI: 1376848002
Provider Name (Legal Business Name): COLUMBIA RIVER ANESTHESIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2011
Last Update Date: 01/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 W ELM AVE
HERMISTON OR
97838-6933
US

IV. Provider business mailing address

1122 W ELM AVE
HERMISTON OR
97838-6933
US

V. Phone/Fax

Practice location:
  • Phone: 307-251-0502
  • Fax:
Mailing address:
  • Phone: 307-251-0502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number090007538CRNA
License Number StateOR

VIII. Authorized Official

Name: JAMES E DUDO
Title or Position: OWNER
Credential: M.D., C.R.N.A.
Phone: 307-251-0502