Provider Demographics
NPI:1336112366
Name:BALTHAZOR, GLENDA K (CRNA)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:K
Last Name:BALTHAZOR
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:GLENDA
Other - Middle Name:
Other - Last Name:WRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5053
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5053
Mailing Address - Country:US
Mailing Address - Phone:605-328-6548
Mailing Address - Fax:605-328-6512
Practice Address - Street 1:1305 W 18TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-0401
Practice Address - Country:US
Practice Address - Phone:605-333-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0307367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5752840Medicaid
SD1655Medicare ID - Type Unspecified
SD5752840Medicaid