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General NPI Number Information
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NPI Number | 1265997985
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Entity Type | Individual
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Provider Name | PAUL WENDELL NICHOLSON CRNA
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Gender | Male
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Dates
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Enumeration Date | 02/06/2019
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Last Update Date | 12/15/2021
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Provider Practice Location Address
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Address Line | 201 CANYON CREST DR
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City | TWIN FALLS
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State | ID
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Zip | 83301-5934
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Country | US
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Telephone | 208-734-7362
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Fax |
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Provider Business Mailing Address
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Address Line | 201 CANYON CREST DR STE 100
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City | TWIN FALLS
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State | ID
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Zip | 83301-5935
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Country | US
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Telephone |
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Fax |
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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 | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 8752157-4406
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License Number State | UT
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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 | 69350
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License Number State | ID
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