Provider Demographics
NPI:1619234655
Name:MURRAY, BRIGHAM DERK (CRNA)
Entity type:Individual
Prefix:
First Name:BRIGHAM
Middle Name:DERK
Last Name:MURRAY
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 3208
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-3208
Mailing Address - Country:US
Mailing Address - Phone:801-941-8794
Mailing Address - Fax:
Practice Address - Street 1:222 W IOWA AVE STE B
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6814
Practice Address - Country:US
Practice Address - Phone:208-467-3432
Practice Address - Fax:208-467-4147
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-16
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRNA-833A367500000X
IDRNA-833367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1619234655Medicaid