Provider Demographics
NPI:1902036734
Name:INNOVATIVE ANESTHESIA
Entity Type:Organization
Organization Name:INNOVATIVE ANESTHESIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-265-3534
Mailing Address - Street 1:PO BOX 591
Mailing Address - Street 2:
Mailing Address - City:SAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83860-0591
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30544 HIGHWAY 200 STE 201
Practice Address - Street 2:PEND OREILLE SURGERY CENTER
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-5005
Practice Address - Country:US
Practice Address - Phone:208-265-8194
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-14
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRNA-491A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty