MEDICARE: ANESTHESIA PUGET SOUND PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	AP30000995	WA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	430043140	OTHER	WA	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	EL3744	OTHER	WA	REGENCE BLUE SHIELD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053523886
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANESTHESIA PUGET SOUND PLLC

Provider Business Mailing Address
First Line	:	PMB 954
Second Line	:
City	:	LAKE STEVENS
State	:	WA
Zip	:	98258
Country	:	US
Telephone Number	:	425-345-1947
Fax Number	:

Provider Business Practice Location Address
First Line	:	1418 E LAKESHORE DRIVE
Second Line	:
City	:	LAKE STEVENS
State	:	WA
Zip	:	98258
Country	:	US
Telephone Number	:	425-345-1947
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	THOMAS STILLMAN ELSEMORE
Credential	:	CRNA
Telephone Number	:	425-345-1947

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	05/06/2008

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