Provider Demographics
NPI:1801273321
Name:PURCELL, BRIAN BLAKE (CRNA)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:BLAKE
Last Name:PURCELL
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 2193
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-2193
Mailing Address - Country:US
Mailing Address - Phone:208-552-8777
Mailing Address - Fax:208-523-2025
Practice Address - Street 1:1485 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1667
Practice Address - Country:US
Practice Address - Phone:208-785-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-05
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRNA-937A367500000X
IDN42090163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1801273321Medicaid