Provider Demographics
NPI:1205842358
Name:SUTHERLAND, BRENT MICHAEL (CRNA)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:MICHAEL
Last Name:SUTHERLAND
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 210
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-0210
Mailing Address - Country:US
Mailing Address - Phone:801-825-4700
Mailing Address - Fax:801-825-9076
Practice Address - Street 1:2532 CORONADO
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-557-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDC146478367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered