Provider Demographics
NPI:1558304329
Name:INTERMOUNTAIN ANESTHESIA, PA
Entity Type:Organization
Organization Name:INTERMOUNTAIN ANESTHESIA, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRNA
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-487-0277
Mailing Address - Street 1:PO BOX 94289, MS 631130
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-6589
Mailing Address - Country:US
Mailing Address - Phone:866-487-0277
Mailing Address - Fax:770-701-6674
Practice Address - Street 1:3100 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7533
Practice Address - Country:US
Practice Address - Phone:208-529-6269
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002712600Medicaid