Provider Demographics
NPI:1104905447
Name:KINGHORN, ROBERT (CRNA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:KINGHORN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1657
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-1657
Mailing Address - Country:US
Mailing Address - Phone:208-734-7362
Mailing Address - Fax:208-733-9463
Practice Address - Street 1:115 FALLS AVE W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3115
Practice Address - Country:US
Practice Address - Phone:208-734-7362
Practice Address - Fax:208-733-9463
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-15840367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID004372800Medicaid
ID004372800Medicaid