Provider Demographics
NPI:1740283456
Name:BOHARSKI, DAVID C (CRNA, FNP)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:C
Last Name:BOHARSKI
Suffix:
Gender:M
Credentials:CRNA, FNP
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 8654
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59904-1654
Mailing Address - Country:US
Mailing Address - Phone:406-270-6240
Mailing Address - Fax:
Practice Address - Street 1:1411 9TH ST S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-4503
Practice Address - Country:US
Practice Address - Phone:406-454-2171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN24307363LF0000X
MT24307367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4305318Medicaid
MTQ39542Medicare UPIN