Provider Demographics
NPI:1114599164
Name:BRISCOE, NATHAN ALLEN (CRNA)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:ALLEN
Last Name:BRISCOE
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 1:3538 N CURT DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5506
Mailing Address - Country:US
Mailing Address - Phone:208-991-8511
Mailing Address - Fax:
Practice Address - Street 1:2537 W STATE ST STE 200
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-2200
Practice Address - Country:US
Practice Address - Phone:208-336-0895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-10
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID54362367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered