Provider Demographics
NPI:1346562113
Name:WATSON, RUSSELL JON (CRNA)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:JON
Last Name:WATSON
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 2936
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-2936
Mailing Address - Country:US
Mailing Address - Phone:208-552-8773
Mailing Address - Fax:208-523-2025
Practice Address - Street 1:351 SW 9TH ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2639
Practice Address - Country:US
Practice Address - Phone:541-881-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201160057CRNA367500000X
IDRNA-912A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1346562113Medicaid
ID1346562113Medicaid