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General NPI Number Information
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NPI Number | 1265425714
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Entity Type | Individual
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Provider Name | ROBERT L ELLISON CRNA
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Gender | Male
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Dates
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Enumeration Date | 08/30/2005
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Last Update Date | 07/13/2010
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Provider Practice Location Address
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Address Line | 2300 W A ST
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City | MOSCOW
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State | ID
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Zip | 83843-4038
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Country | US
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Telephone | 208-883-1500
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Fax | 208-882-7701
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Provider Business Mailing Address
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Address Line | PO BOX 1829
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City | COEUR D ALENE
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State | ID
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Zip | 83816-1829
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Country | US
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Telephone | 208-667-9334
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Fax | 208-664-2341
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | N13917
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | RNA-209
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | AP30004667
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License Number State | WA
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