Provider Demographics
NPI:1093784183
Name:IVEY, WILLIE D (CRNA)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:D
Last Name:IVEY
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 1:601 W 5TH AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2715
Mailing Address - Country:US
Mailing Address - Phone:509-344-2663
Mailing Address - Fax:509-624-9179
Practice Address - Street 1:601 W 5TH AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2756
Practice Address - Country:US
Practice Address - Phone:509-344-2663
Practice Address - Fax:509-624-9179
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00144573367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0185166OtherDEPT OF LABOR & INDUSTRIE
WA28403OtherGROUP HEALTH NW
WA9634601Medicaid
WA2855IVOtherASURIS NW HEALTH
WA8938961OtherCRIME VICTIMS
MT4303910Medicaid
ID000010147505OtherREGENCE BLUE SHIELD OF ID
WAP00126952OtherRR MEDICARE
WA28403OtherGROUP HEALTH NW
WAG8803303Medicare ID - Type Unspecified