Provider Demographics
NPI:1275074486
Name:MOSCOW MOUNTAIN ANESTHESIA, PLLC
Entity Type:Organization
Organization Name:MOSCOW MOUNTAIN ANESTHESIA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:WINTERBOTTOM
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:208-883-1500
Mailing Address - Street 1:2300 W A ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-4038
Mailing Address - Country:US
Mailing Address - Phone:208-883-1500
Mailing Address - Fax:208-882-7701
Practice Address - Street 1:2300 W A ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-4038
Practice Address - Country:US
Practice Address - Phone:208-883-1500
Practice Address - Fax:208-882-7701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-20
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty