Provider Demographics
NPI:1740304732
Name:ALLEN, DAVID (CRNA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:ALLEN
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 1:3235 N TOWERBRIDGE WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5721
Mailing Address - Country:US
Mailing Address - Phone:208-895-6611
Mailing Address - Fax:
Practice Address - Street 1:3235 N TOWERBRIDGE WAY STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5721
Practice Address - Country:US
Practice Address - Phone:208-895-6611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-17
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRNA-680A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2737024Medicaid
OH2737024Medicaid