Provider Demographics
NPI:1356912257
Name:ENTZEROTH, TIMOTHY RICHARD (CRNA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:RICHARD
Last Name:ENTZEROTH
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 1:7404 SADDLEBROOK LOOP
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-5909
Mailing Address - Country:US
Mailing Address - Phone:636-288-6279
Mailing Address - Fax:
Practice Address - Street 1:2811 TIETON DR
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3761
Practice Address - Country:US
Practice Address - Phone:509-575-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-02
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO133972367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered