NPIMap

Organization Active NPI

Blue Lakes Anesthesia

  • Certified Registered Nurse Anesthetist
  • Twin Falls, ID
National Provider Identifier
1073344651
Registry record updated Aug 21, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Certified Registered Nurse AnesthetistTaxonomy code 367500000X
Legal business name
BLUE LAKES ANESTHESIA
Practice address
2092 Dawson Dr
Twin Falls, ID 83301-3195
Phone
(208) 734-7362
NPI assigned
Aug 13, 2024
Last updated
Aug 21, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 21, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Thad Hollist, CRNANPI 1639521024
Title
Managing Member
Phone
(208) 520-0035

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Certified Registered Nurse Anesthetist 367500000X NU Primary

Addresses

Primary practice location

2092 Dawson Dr
Twin Falls, ID 83301-3195

Mailing address

3849A N 3700 E
Hansen, ID 83334-5039
Phone (208) 734-7362

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20240911004348 ID Part B Supplier - Clinic/Group Practice 1951841303 Receives reassigned benefits from 7 practitioners
Practice locations: Twin Falls, ID

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 15

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 15

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1723507200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1724198400000",
    "number": "1073344651",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3849A N 3700 E",
            "city": "HANSEN",
            "state": "ID",
            "postal_code": "833345039",
            "telephone_number": "208-734-7362",
            "fax_number": "208-733-9463"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2092 DAWSON DR",
            "city": "TWIN FALLS",
            "state": "ID",
            "postal_code": "833013195",
            "telephone_number": "208-734-7362"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLUE LAKES ANESTHESIA",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-08-13",
        "last_updated": "2024-08-21",
        "certification_date": "2024-08-21",
        "status": "A",
        "authorized_official_last_name": "HOLLIST",
        "authorized_official_first_name": "THAD",
        "authorized_official_title_or_position": "MANAGING MEMBER",
        "authorized_official_telephone_number": "208-520-0035",
        "authorized_official_credential": "CRNA"
    },
    "taxonomies": [
        {
            "code": "367500000X",
            "taxonomy_group": "",
            "desc": "Nurse Anesthetist, Certified Registered",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Twin Falls, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 21, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.