Provider Demographics
NPI:1568412278
Name:KNIEVEL, DALE T (CRNA)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:T
Last Name:KNIEVEL
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 4107
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-4107
Mailing Address - Country:US
Mailing Address - Phone:208-232-7760
Mailing Address - Fax:208-232-1950
Practice Address - Street 1:1950 E CLARK ST
Practice Address - Street 2:SUITE G
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3314
Practice Address - Country:US
Practice Address - Phone:208-232-7760
Practice Address - Fax:208-232-1950
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN10107163W00000X
IDRNA-33367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID004373000Medicaid
ID004373000Medicaid