=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831598457
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PANACEA ANESTHESIA SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2014
-----------------------------------------------------
Last Update Date | 06/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 577 AIRPORT RD
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97504-4159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-608-2590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4069
-----------------------------------------------------
City | EVERETT
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98204-0007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-407-1500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CRNA
-----------------------------------------------------
Name | STEVEN SCOTT CROWTHERS
-----------------------------------------------------
Credential | CRNA
-----------------------------------------------------
Telephone | 970-946-2918
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------