1821003781 NPI number — MARIA C KONEN CRNA

Table of content: MARIA C KONEN CRNA (NPI 1821003781)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821003781 NPI number — MARIA C KONEN CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KONEN
Provider First Name:
MARIA
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821003781
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOSCOW
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83843-3056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-883-6350
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSCOW
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83843-3056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-883-6350
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  N28761 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 14-93064-111 . This is a "KANSAS LICENSE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: N28761 . This is a "IDAHO LICENSE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 9650516 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00357946 . This is a "RR MEDICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: A4598 . This is a "BC ID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: P00357946 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 807575400 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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