Provider Demographics
NPI:1497859037
Name:THEOBALD, EVAN B (CRNA)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:B
Last Name:THEOBALD
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 1:32 W 1320 S
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:UT
Mailing Address - Zip Code:84651-3012
Mailing Address - Country:US
Mailing Address - Phone:801-465-3844
Mailing Address - Fax:
Practice Address - Street 1:1000 E 100 N
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-1600
Practice Address - Country:US
Practice Address - Phone:800-748-4868
Practice Address - Fax:801-733-5872
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT375417-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT34456OtherHEALTHY U
UT894814OtherDESERET MUTUAL
UTP00215104Medicare ID - Type UnspecifiedRAILROAD MEDICARE