Provider Demographics
NPI:1578544516
Name:THIBODEAUX, SAMUEL J (CRNA)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:J
Last Name:THIBODEAUX
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 34120
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89533-4120
Mailing Address - Country:US
Mailing Address - Phone:775-747-5050
Mailing Address - Fax:775-747-5005
Practice Address - Street 1:271 OBSERVATORY AVE
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5757
Practice Address - Country:US
Practice Address - Phone:707-462-0681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD105288367500000X
CANA3796367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA39651OtherWELLMARK BCBS
IA0469627Medicaid
Q47201Medicare UPIN
CADW596ZMedicare PIN
IA0469627Medicaid
IAI15464Medicare PIN