Provider Demographics
NPI:1790895068
Name:PULLMAN ANESTHESIA ASSOCIATES PS
Entity Type:Organization
Organization Name:PULLMAN ANESTHESIA ASSOCIATES PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:COREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:509-413-3147
Mailing Address - Street 1:PO BOX 29650
Mailing Address - Street 2:DEPT # 880129
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038-9650
Mailing Address - Country:US
Mailing Address - Phone:509-413-3147
Mailing Address - Fax:509-336-7599
Practice Address - Street 1:835 SE BISHOP BLVD
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5512
Practice Address - Country:US
Practice Address - Phone:509-413-3147
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9609173Medicaid
WA=========OtherTAX ID
WAG000302700Medicare PIN