Provider Demographics
NPI:1538381397
Name:SPANTON, KENNETH A (CRNA)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:A
Last Name:SPANTON
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 1:315 N 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344-1254
Mailing Address - Country:US
Mailing Address - Phone:509-488-2636
Mailing Address - Fax:509-331-2627
Practice Address - Street 1:315 N 14TH AVE
Practice Address - Street 2:
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-1254
Practice Address - Country:US
Practice Address - Phone:509-488-2636
Practice Address - Fax:509-331-2627
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005325367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9021494Medicaid
WAR31545Medicare UPIN