Provider Demographics
NPI:1740285246
Name:ANDREGG, GARY B (CRNA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:B
Last Name:ANDREGG
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 1:17 EAGEN LN
Mailing Address - Street 2:
Mailing Address - City:HOPE
Mailing Address - State:ID
Mailing Address - Zip Code:83836-9783
Mailing Address - Country:US
Mailing Address - Phone:208-264-5487
Mailing Address - Fax:
Practice Address - Street 1:1593 E POLSTON AVE
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5326
Practice Address - Country:US
Practice Address - Phone:208-262-2314
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRN-158174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1602241Medicare ID - Type Unspecified