MEDICARE: THOMAS STILLMAN ELSEMORE 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	163WX1100X	Ophthalmic Registered Nurse	RN00061277	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	202723	OTHER	WA	L & I

General Provider Information

NPI Number	:	1407832983
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS STILLMAN ELSEMORE CRNA

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 DR
Second Line	:
City	:	LAKE STEVENS
State	:	WA
Zip	:	98258-8638
Country	:	US
Telephone Number	:	425-334-8081
Fax Number	:

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

Provider Enumeration Date	:	12/16/2005
Last Update Date	:	01/05/2010

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