Provider Demographics
NPI:1407832983
Name:ELSEMORE, THOMAS STILLMAN (CRNA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:STILLMAN
Last Name:ELSEMORE
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:PMB 954
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258
Mailing Address - Country:US
Mailing Address - Phone:425-345-1947
Mailing Address - Fax:
Practice Address - Street 1:1418 E LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-8638
Practice Address - Country:US
Practice Address - Phone:425-334-8081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00061277163WX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX1100XNursing Service ProvidersRegistered NurseOphthalmic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9618489Medicaid
WA202723OtherL & I
WA9618489Medicaid
WAR30290Medicare UPIN
WA000170112Medicare ID - Type Unspecified
WA202723OtherL & I