Provider Demographics
NPI:1417065152
Name:OVERTON-STIFF PROFESSIONAL ANESTHESIA SERVICE LTD
Entity Type:Organization
Organization Name:OVERTON-STIFF PROFESSIONAL ANESTHESIA SERVICE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARGUERITE
Authorized Official - Middle Name:
Authorized Official - Last Name:OVERTON
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:208-939-3255
Mailing Address - Street 1:PO BOX 2203
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-2203
Mailing Address - Country:US
Mailing Address - Phone:208-525-2090
Mailing Address - Fax:208-523-8978
Practice Address - Street 1:6302 TALCREST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1207
Practice Address - Country:US
Practice Address - Phone:208-939-3255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN25778367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR107247Medicare PIN