=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699394015
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIAN R HOBBS CRNA PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2020
-----------------------------------------------------
Last Update Date | 04/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3369 MERLIN DR STE A
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404-7405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-525-2090
-----------------------------------------------------
Fax | 208-523-8978
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3555 POTOMAC WAY
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404-4985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-525-2090
-----------------------------------------------------
Fax | 208-523-8978
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRIAN R HOBBS
-----------------------------------------------------
Credential | CRNA
-----------------------------------------------------
Telephone | 208-390-1391
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------