Provider Demographics
NPI:1972763381
Name:GUERCIO, BENJAMIN (CRNA)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:GUERCIO
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 1:98 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-5415
Mailing Address - Country:US
Mailing Address - Phone:801-300-8071
Mailing Address - Fax:
Practice Address - Street 1:1224 8TH ST
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:ID
Practice Address - Zip Code:83350-1527
Practice Address - Country:US
Practice Address - Phone:208-436-0481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT51561064406367500000X
IDN-44886367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered