Provider Demographics
NPI:1215968961
Name:BOGSRUD, THEODORE W (CRNA)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:W
Last Name:BOGSRUD
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 1:2517 NE KRESKY AVE
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-2409
Mailing Address - Country:US
Mailing Address - Phone:360-242-3008
Mailing Address - Fax:360-807-7687
Practice Address - Street 1:16818 E DESMET CT
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-3542
Practice Address - Country:US
Practice Address - Phone:509-456-5380
Practice Address - Fax:509-456-5381
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID28189367500000X
MTNUR-RN-LIC-101109367500000X
WAAP30004818367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA430044217OtherRAILROAD MEDICARE
WA9630542Medicaid
WA430061770OtherRAILROAD MEDICARE
MTP00335315OtherRAILROAD MEDICARE
WA430048398OtherRAILROAD MEDICARE
MTM011002649OtherMEDICARE MT
ID1204355OtherMEDICARE ID
ID430062516OtherRAILROAD MEDICARE
NMNM302933OtherMEDICARE NM
WA430061770OtherRAILROAD MEDICARE
WA430044217OtherRAILROAD MEDICARE
S27000Medicare UPIN
WAG8859285Medicare PIN
MT000006647Medicare PIN