Healthcare Provider Details

I. General information

NPI: 1346562113
Provider Name (Legal Business Name): RUSSELL JON WATSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 SW 9TH ST
ONTARIO OR
97914-2639
US

IV. Provider business mailing address

PO BOX 2936
IDAHO FALLS ID
83403-2936
US

V. Phone/Fax

Practice location:
  • Phone: 541-881-7000
  • Fax:
Mailing address:
  • Phone: 208-552-8773
  • Fax: 208-523-2025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number201160057CRNA
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA-912A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: