Provider Demographics
NPI:1407353428
Name:ADVANCED ANESTHESIA, LLC
Entity Type:Organization
Organization Name:ADVANCED ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DORIAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:GRUNIG
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:208-390-7757
Mailing Address - Street 1:115 CANYON RD
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254-1218
Mailing Address - Country:US
Mailing Address - Phone:208-390-7757
Mailing Address - Fax:
Practice Address - Street 1:1155 POCATELLO CREEK RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2949
Practice Address - Country:US
Practice Address - Phone:208-238-6337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RNA613A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty