Provider Demographics
NPI:1356325666
Name:SKINNER, JOSEPH CARROLL JR (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:CARROLL
Last Name:SKINNER
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:90 HOPE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME AFB
Mailing Address - State:ID
Mailing Address - Zip Code:83648
Mailing Address - Country:US
Mailing Address - Phone:208-828-7768
Mailing Address - Fax:
Practice Address - Street 1:366 MDOS, SGOSA
Practice Address - Street 2:90 HOPE DRIVE
Practice Address - City:MOUNTAIN HOME AFB
Practice Address - State:ID
Practice Address - Zip Code:83648
Practice Address - Country:US
Practice Address - Phone:208-828-7370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRNA648A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered