=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215652375
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL ROBERT ALLEN CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2022
-----------------------------------------------------
Last Update Date | 08/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2537 W STATE ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83702-2200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-336-0895
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4172 S SELATIR WAY
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-8489
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-921-4113
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 75374
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine Registered Nurse
-----------------------------------------------------
License Number | 44136
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------