Provider Demographics
NPI:1689648818
Name:HERZOG, TODD WILLIAM (CRNA ARNP)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:WILLIAM
Last Name:HERZOG
Suffix:
Gender:M
Credentials:CRNA ARNP
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 455
Mailing Address - Street 2:
Mailing Address - City:HANSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98340-0455
Mailing Address - Country:US
Mailing Address - Phone:360-908-2457
Mailing Address - Fax:360-638-0058
Practice Address - Street 1:41487 NE FOULWEATHER BLUFF ROAD
Practice Address - Street 2:
Practice Address - City:HANSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98340-0455
Practice Address - Country:US
Practice Address - Phone:360-908-2457
Practice Address - Fax:360-638-0058
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30002036363L00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0137504OtherLABOR AND INDUSTRIES
WAHE2316OtherREGENCE BLUE SHIELD
WA430049902OtherRAILROAD MEDICARE
WA9636366Medicaid
WAHE2316OtherREGENCE BLUE SHIELD
WAG8867265Medicare PIN