Healthcare Provider Details

I. General information

NPI: 1407832983
Provider Name (Legal Business Name): THOMAS STILLMAN ELSEMORE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 01/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1418 E LAKESHORE DR
LAKE STEVENS WA
98258-8638
US

IV. Provider business mailing address

PMB 954
LAKE STEVENS WA
98258
US

V. Phone/Fax

Practice location:
  • Phone: 425-334-8081
  • Fax:
Mailing address:
  • Phone: 425-345-1947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX1100X
TaxonomyOphthalmic Registered Nurse
License NumberRN00061277
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: