Provider Demographics
NPI:1720193410
Name:SIMON, DAVID H (CRNA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:H
Last Name:SIMON
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 1:1605 S KIMBALL AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4548
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:208-342-2087
Practice Address - Fax:208-336-1954
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRNA267367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010136818OtherBLUE SHIELD
IDA2286OtherBLUE CROSS
ID1601795Medicare ID - Type UnspecifiedMEDICARE