Provider Demographics
NPI:1215652375
Name:ALLEN, MICHAEL ROBERT (CRNA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
Last Name:ALLEN
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 1:7336 W COHO DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-5691
Mailing Address - Country:US
Mailing Address - Phone:208-921-4113
Mailing Address - Fax:
Practice Address - Street 1:2537 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-2200
Practice Address - Country:US
Practice Address - Phone:208-336-0895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-11
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID44136163WC0200X
ID75374367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine