Provider Demographics
NPI:1184695140
Name:ELSEMORE, ERIC A (CRNA)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:A
Last Name:ELSEMORE
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:PO BOX 1506
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0409
Mailing Address - Country:US
Mailing Address - Phone:360-242-3010
Mailing Address - Fax:
Practice Address - Street 1:2517 NE KRESKY AVE
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-2409
Practice Address - Country:US
Practice Address - Phone:360-748-8632
Practice Address - Fax:360-748-3869
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN0117713163W00000X
WAAP30005759367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8897483OtherMEDICARE WA
WAG8898112OtherMEDICARE WA
WAG8900477OtherMEDICARE WA
WAG8967168OtherMEDICARE WA
WA1004358Medicaid
WAP00086114OtherRAILROAD MEDICARE
WAG8860075Medicare PIN
WAG8874716Medicare PIN