Provider Demographics
NPI:1235282443
Name:PACIFIC NORTHWEST ANESTHESIA SERVICES, INC., P.C.
Entity Type:Organization
Organization Name:PACIFIC NORTHWEST ANESTHESIA SERVICES, INC., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:HERZOG
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA, ARNP
Authorized Official - Phone:360-908-2457
Mailing Address - Street 1:PO BOX 455
Mailing Address - Street 2:PO BOX 455
Mailing Address - City:HANSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98340-0455
Mailing Address - Country:US
Mailing Address - Phone:360-908-2457
Mailing Address - Fax:360-638-0058
Practice Address - Street 1:41487 NE FOULWEATHER BLUFF ROAD
Practice Address - Street 2:
Practice Address - City:HANSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98340-0455
Practice Address - Country:US
Practice Address - Phone:360-908-2457
Practice Address - Fax:360-638-0058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30002036367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADG0886OtherRAILROAD MEDICARE
WA9636366Medicaid
WA0137504OtherLABOR AND INDUSTRIES
WAREGENCE BLUE SHIELDOtherHE2316
WAG8867264Medicare PIN
WA9636366Medicaid