Provider Demographics
NPI:1912120551
Name:MARSHALL, JASON D (CRNA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:D
Last Name:MARSHALL
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 1:2204 IRONWOOD PL STE B
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2662
Mailing Address - Country:US
Mailing Address - Phone:208-765-8585
Mailing Address - Fax:208-765-8486
Practice Address - Street 1:2003 KOOTENAI HEALTH WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-6051
Practice Address - Country:US
Practice Address - Phone:208-765-8585
Practice Address - Fax:208-765-8486
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT22689367500000X
IDRNA-709A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1912120551Medicaid
MT1912120551Medicaid
MTPENDINGMedicaid