Healthcare Provider Details

I. General information

NPI: 1134448996
Provider Name (Legal Business Name): THEODORE RUSSELL GAVEL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2010
Last Update Date: 05/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 S SCHEUBER RD PMG SW WA CENTRALIA ANESTHESIOLOGY
CENTRALIA WA
98531-9027
US

IV. Provider business mailing address

PO BOX 3360
PORTLAND OR
97208-3360
US

V. Phone/Fax

Practice location:
  • Phone: 360-736-2803
  • Fax:
Mailing address:
  • Phone: 866-747-2455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN584062
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP60443744
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: