Healthcare Provider Details

I. General information

NPI: 1063961928
Provider Name (Legal Business Name): CHASE BAZIL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2016
Last Update Date: 11/11/2022
Certification Date: 11/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 N STATE ST STE 105
PROVO UT
84604-1354
US

IV. Provider business mailing address

348 W 90 S
SALEM UT
84653-9158
US

V. Phone/Fax

Practice location:
  • Phone: 801-655-5245
  • Fax:
Mailing address:
  • Phone: 208-351-0283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9902165-4406
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9902165-8901
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: