Healthcare Provider Details

I. General information

NPI: 1023063278
Provider Name (Legal Business Name): PHYSICIAN ANESTHESIA GROUP PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 W 5TH AVE SUITE 230E
SPOKANE WA
99204-4880
US

IV. Provider business mailing address

104 W 5TH AVE SUITE 230E
SPOKANE WA
99204-4880
US

V. Phone/Fax

Practice location:
  • Phone: 509-838-8561
  • Fax: 509-835-4058
Mailing address:
  • Phone: 509-838-8561
  • Fax: 509-835-4058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: DR. REX PORTER
Title or Position: DELEGATE
Credential: MD
Phone: 509-838-8561