Provider Demographics
NPI:1073344651
Name:BLUE LAKES ANESTHESIA
Entity type:Organization
Organization Name:BLUE LAKES ANESTHESIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:THAD
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLIST
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:208-520-0035
Mailing Address - Street 1:3849A N 3700 E
Mailing Address - Street 2:
Mailing Address - City:HANSEN
Mailing Address - State:ID
Mailing Address - Zip Code:83334-5039
Mailing Address - Country:US
Mailing Address - Phone:208-734-7362
Mailing Address - Fax:208-733-9463
Practice Address - Street 1:2092 DAWSON DR
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3195
Practice Address - Country:US
Practice Address - Phone:208-734-7362
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-13
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty