Provider Demographics
NPI:1669654562
Name:ANDERSON, RICK M (CRNA)
Entity Type:Individual
Prefix:
First Name:RICK
Middle Name:M
Last Name:ANDERSON
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 1:1425 W RIVER ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6861
Mailing Address - Country:US
Mailing Address - Phone:208-455-1400
Mailing Address - Fax:208-455-1449
Practice Address - Street 1:1425 W RIVER ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6861
Practice Address - Country:US
Practice Address - Phone:208-455-1400
Practice Address - Fax:208-455-1449
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN7643207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDA2278OtherBLUE CROSS OF IDAHO