Provider Demographics
NPI:1467863829
Name:GUNDERSEN, GRANT (CNRA)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:GUNDERSEN
Suffix:
Gender:M
Credentials:CNRA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:646 W 300 S
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-6334
Mailing Address - Country:US
Mailing Address - Phone:208-760-7529
Mailing Address - Fax:
Practice Address - Street 1:646 W 300 S
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-6334
Practice Address - Country:US
Practice Address - Phone:208-760-7529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-19
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-38994367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered