1740275924 NPI number — LORI CARMEN CRNA

Table of content: LORI CARMEN CRNA (NPI 1740275924)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740275924 NPI number — LORI CARMEN CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARMEN
Provider First Name:
LORI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740275924
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 CORDOVA PL
Provider Second Line Business Mailing Address:
# 712
Provider Business Mailing Address City Name:
SANTA FE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87505-1725
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-747-8639
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 SPRUCE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ESPANOLA
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87532-3456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-753-7111
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  R47417 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 430074229 . This is a "RAILROAD MEDICARE INDIVID" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: NM006426 . This is a "BCB NM - INDIVIDUAL" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 17104505 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com