Individual
ROBERT L ELLISON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
2300 W A ST, MOSCOW, ID 83843-4038
(208) 883-1500
(208) 882-7701
Mailing address
PO BOX 1829, COEUR D ALENE, ID 83816-1829
(208) 667-9334
(208) 664-2341
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
N13917
ID
367500000X
Certified Registered Nurse Anesthetist
AP30004667
WA
367500000X
Certified Registered Nurse Anesthetist
Primary
RNA-209
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
805788500
—
ID
05
—
9628264
—
WA
01
—
A3565
BC ID
ID
01
—
N13917
IDAHO LICENSE
ID
01
—
P00137189
RAILROAD MEDICARE
—
Enumeration date
08/30/2005
Last updated
07/13/2010
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