Provider Demographics
NPI:1114980455
Name:GERHARD, RICHARD J (CRNA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:GERHARD
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 1:3043 N RAMPART RD
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-7852
Mailing Address - Country:US
Mailing Address - Phone:208-765-4777
Mailing Address - Fax:
Practice Address - Street 1:1705 N GOVERNMENT WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-3444
Practice Address - Country:US
Practice Address - Phone:208-765-8585
Practice Address - Fax:208-765-8486
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRNA22367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID004368400Medicaid
ID1600171Medicare ID - Type UnspecifiedPROVIDER NUMBER