Provider Demographics
NPI:1558454876
Name:ALLEN, STEPHEN D (CRNA)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:D
Last Name:ALLEN
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 1:353 FAIRMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7350
Mailing Address - Country:US
Mailing Address - Phone:605-430-3109
Mailing Address - Fax:
Practice Address - Street 1:353 FAIRMONT BLVD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7375
Practice Address - Country:US
Practice Address - Phone:605-755-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR031003367500000X
SDCR000463367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5751232Medicaid
SD7776Medicare ID - Type Unspecified