Provider Demographics
NPI:1184863219
Name:NELSON, TAYLOR KELLER (CRNA)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:KELLER
Last Name:NELSON
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 1:120 EAST HOWARD AVENUE
Mailing Address - Street 2:TETON VALLEY HEALTH CARE
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422-5112
Mailing Address - Country:US
Mailing Address - Phone:208-354-6302
Mailing Address - Fax:208-354-3158
Practice Address - Street 1:120 EAST HOWARD AVENUE
Practice Address - Street 2:TETON VALLEY HEALTH CARE
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422-5112
Practice Address - Country:US
Practice Address - Phone:208-354-6302
Practice Address - Fax:208-354-3158
Is Sole Proprietor?:No
Enumeration Date:2009-02-12
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRNA746367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1605321Medicare PIN