Provider Demographics
NPI:1205981818
Name:CRESCENT CITY NURSE ANESTHETIST
Entity type:Organization
Organization Name:CRESCENT CITY NURSE ANESTHETIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:503-650-4359
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-0249
Mailing Address - Country:US
Mailing Address - Phone:503-650-4359
Mailing Address - Fax:503-650-6913
Practice Address - Street 1:800 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-8359
Practice Address - Country:US
Practice Address - Phone:503-650-4359
Practice Address - Fax:503-650-6913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2015-06-10
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
CAZZZ29625ZMedicare PIN