Provider Demographics
NPI:1598722241
Name:KIDWELL, RICHARD CHARLES (CRNA)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:CHARLES
Last Name:KIDWELL
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 1529
Mailing Address - Street 2:
Mailing Address - City:ELKO
Mailing Address - State:NV
Mailing Address - Zip Code:89803-1529
Mailing Address - Country:US
Mailing Address - Phone:775-738-2220
Mailing Address - Fax:775-738-3751
Practice Address - Street 1:855 GOLF COURSE RD
Practice Address - Street 2:
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801
Practice Address - Country:US
Practice Address - Phone:775-753-4700
Practice Address - Fax:775-753-4703
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCRNA000017367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV38296Medicare ID - Type Unspecified