Provider Demographics
NPI:1497395578
Name:SELVIDGE, COLTON (CRNA)
Entity Type:Individual
Prefix:
First Name:COLTON
Middle Name:
Last Name:SELVIDGE
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:PO BOX 22407
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126-0407
Mailing Address - Country:US
Mailing Address - Phone:636-386-7222
Mailing Address - Fax:636-386-7810
Practice Address - Street 1:10010 KENNERLY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2106
Practice Address - Country:US
Practice Address - Phone:636-386-7222
Practice Address - Fax:636-386-7222
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN700062367500000X
MO2021020995367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered