Provider Demographics
NPI:1518992858
Name:NORDSTROM, BRIAN N (CRNA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:N
Last Name:NORDSTROM
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 1:660 S COOLIDGE ST
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-1872
Mailing Address - Country:US
Mailing Address - Phone:509-793-9715
Mailing Address - Fax:509-764-3244
Practice Address - Street 1:801 E WHEELER RD
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1820
Practice Address - Country:US
Practice Address - Phone:509-765-5606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7725758367500000X
WAAP30007782367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM202005544Medicaid
NM202005544OtherPRESBYTERIAN COMMERCIAL
NM59223766Medicaid
TX86228UOtherBC/BS
TX180399101Medicaid
TX86243UOtherHMO BLUE
TX134895101Medicaid
TX134895100OtherFIRSTCARE COMMERCIAL
WA1044563Medicaid
OK200077930AMedicaid