MEDICARE: BRENT MICHAEL SUTHERLAND CRNA

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	C146478	ID

General Provider Information

NPI Number	:	1205842358
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENT MICHAEL SUTHERLAND CRNA

Provider Business Mailing Address
First Line	:	PO BOX 210
Second Line	:
City	:	ROY
State	:	UT
Zip	:	84067-0210
Country	:	US
Telephone Number	:	801-825-4700
Fax Number	:	801-825-9076

Provider Business Practice Location Address
First Line	:	2532 CORONADO
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404
Country	:	US
Telephone Number	:	208-557-2700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	07/08/2007

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