Provider Demographics
NPI:1215045307
Name:STURDEVANT, ALLEN RAY (CRNA)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:RAY
Last Name:STURDEVANT
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 1617
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362
Mailing Address - Country:US
Mailing Address - Phone:360-452-5648
Mailing Address - Fax:360-452-5648
Practice Address - Street 1:203 S WESTERN AVE
Practice Address - Street 2:NORTH VALLEY HOSPITAL
Practice Address - City:TONASKET
Practice Address - State:WA
Practice Address - Zip Code:98855
Practice Address - Country:US
Practice Address - Phone:509-486-2151
Practice Address - Fax:509-486-3176
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAR30003006367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
38334OtherCRNA CERTIFICATION #
NA0894Medicare ID - Type Unspecified