Healthcare Provider Details

I. General information

NPI: 1902125628
Provider Name (Legal Business Name): TIMOTHY HALL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2010
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3927 RUCKER AVE
EVERETT WA
98201-4833
US

IV. Provider business mailing address

PO BOX 5127
EVERETT WA
98206-5127
US

V. Phone/Fax

Practice location:
  • Phone: 425-259-0966
  • Fax:
Mailing address:
  • Phone: 206-860-5414
  • Fax: 206-720-8462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP60469187
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: