Provider Demographics
NPI:1326239419
Name:KEZELE, JOHN THOMAS III (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
Last Name:KEZELE
Suffix:III
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 1:104 N BEAR RIVER BLFS
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:ID
Mailing Address - Zip Code:83263-5184
Mailing Address - Country:US
Mailing Address - Phone:208-852-2019
Mailing Address - Fax:208-852-7173
Practice Address - Street 1:44 N 100 E
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:ID
Practice Address - Zip Code:83263-1326
Practice Address - Country:US
Practice Address - Phone:208-852-0137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRNA-366A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0015341Medicaid