Provider Demographics
NPI:1265425714
Name:ELLISON, ROBERT L (CRNA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:ELLISON
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 1829
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83816-1829
Mailing Address - Country:US
Mailing Address - Phone:208-667-9334
Mailing Address - Fax:208-664-2341
Practice Address - Street 1:2300 W A ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-4038
Practice Address - Country:US
Practice Address - Phone:208-883-1500
Practice Address - Fax:208-882-7701
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN13917207L00000X
IDRNA-209367500000X
WAAP30004667367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9628264Medicaid
IDA3565OtherBC ID
IDN13917OtherIDAHO LICENSE
P00137189OtherRAILROAD MEDICARE
ID805788500Medicaid
P00137189OtherRAILROAD MEDICARE