Provider Demographics
NPI:1679545099
Name:SKOUSEN, PAUL O (CRNA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:O
Last Name:SKOUSEN
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 1:2610 E UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-8436
Mailing Address - Country:US
Mailing Address - Phone:480-892-8400
Mailing Address - Fax:480-892-9533
Practice Address - Street 1:1055 S STAPLEY DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204
Practice Address - Country:US
Practice Address - Phone:480-833-9100
Practice Address - Fax:480-833-6000
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCRNA0261367500000X
AZ053540163WX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WX1100XNursing Service ProvidersRegistered NurseOphthalmic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ82802Medicare PIN
AZZ82800Medicare PIN
AZZ82794Medicare PIN
AZP54308Medicare UPIN
AZZ82796Medicare PIN
AZZ82798Medicare PIN