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General NPI Number Information
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NPI Number | 1831278076
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Entity Type | Organization
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Legal Business Name | IDAHO ANESTHESIA
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Dates
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Enumeration Date | 11/06/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 650 ADDISON AVE W
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City | TWIN FALLS
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State | ID
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Zip | 83301-5444
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Country | US
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Telephone | 208-525-2090
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Fax | 208-525-2662
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Provider Business Mailing Address
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Address Line | PO BOX 1545
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City | IDAHO FALLS
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State | ID
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Zip | 83403-1545
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Country | US
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Telephone | 208-525-2090
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Fax | 208-525-2662
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Authorized Official
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Title or Position | OWNER
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Name | ROBERT KINGHORN
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Credential | CRNA
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Telephone | 208-525-2090
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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 | N-15840
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License Number State | ID
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