Individual
CASSIDY B WATERMAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
1950 E CLARK ST, SUITE G, POCATELLO, ID 83201-3314
(208) 232-7760
(208) 232-1950
Mailing address
777 HOSPITAL WAY, POCATELLO, ID 83201-5175
(208) 240-0735
(208) 232-1950
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
RNA-781
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1604930
MEDICARE PTAN
ID
01
—
CD5673
RR GROUP LEGACY NUMBER
ID
01
—
P00956855
INDIVIDUAL RR MEDICARE
—
Enumeration date
10/20/2010
Last updated
10/19/2023
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