Provider Demographics
NPI:1598808107
Name:TREASURE VALLEY ANESTHESIA, PLLC
Entity Type:Organization
Organization Name:TREASURE VALLEY ANESTHESIA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CROFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-525-2090
Mailing Address - Street 1:1601 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6313
Mailing Address - Country:US
Mailing Address - Phone:208-525-2090
Mailing Address - Fax:208-525-2662
Practice Address - Street 1:1400 W BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5233
Practice Address - Country:US
Practice Address - Phone:208-378-9295
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRNA-36367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDA0348OtherBLUE CROSS
ID1600297Medicare ID - Type Unspecified