Provider Demographics
NPI:1043568892
Name:ANDERSON, JAXON DEAN (CRNA)
Entity Type:Individual
Prefix:
First Name:JAXON
Middle Name:DEAN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4268
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4268
Mailing Address - Country:US
Mailing Address - Phone:503-372-2740
Mailing Address - Fax:503-372-2754
Practice Address - Street 1:2325 CORONADO ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7407
Practice Address - Country:US
Practice Address - Phone:208-557-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-36657163W00000X
ID847A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse