Healthcare Provider Details

I. General information

NPI: 1750966537
Provider Name (Legal Business Name): CHANCE RAVER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2021
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W 8TH AVE
SPOKANE WA
99204-2364
US

IV. Provider business mailing address

1113 E ADELINE AVE
COEUR D ALENE ID
83814-4426
US

V. Phone/Fax

Practice location:
  • Phone: 509-474-3131
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN60786152
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2861260
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: