Individual
CODY LAMAR OLIVERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
3100 CHANNING WAY, IDAHO FALLS, ID 83404-7533
(208) 529-6111
Mailing address
PO BOX 94289, MS 631130, SEATTLE, WA 98124
(866) 487-0277
(770) 701-6674
Taxonomy
Speciality
Code
Description
License number
State
163WC0200X
Critical Care Medicine Registered Nurse
48308
ID
367500000X
Certified Registered Nurse Anesthetist
Primary
62583
ID
Other
Enumeration date
07/29/2019
Last updated
09/20/2019
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