1376840736 NPI number — MRS. JESSICA ANN BURTON-VIGIL CRNA

Table of content: MRS. JESSICA ANN BURTON-VIGIL CRNA (NPI 1376840736)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376840736 NPI number — MRS. JESSICA ANN BURTON-VIGIL CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURTON-VIGIL
Provider First Name:
JESSICA
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
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:
1376840736
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2247 CALLE CACIQUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA FE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87505-4944
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-351-6025
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2247 CALLE CACIQUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87505-4944
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-351-6025
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/22/2011

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:  APN.0990494-CRNA , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 601718 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01126137 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 04035054 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 16834542 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1376840736 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 74659065 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00971956 . This is a "RR MEDICARE PTAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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