1790229193 NPI number — FREELANCE ANESTHESIA COLORADO LLC

Table of content: (NPI 1790229193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790229193 NPI number — FREELANCE ANESTHESIA COLORADO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FREELANCE ANESTHESIA COLORADO LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1790229193
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3134 10TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOULDER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80304-2524
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-653-9698
Provider Business Mailing Address Fax Number:
866-550-2242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18801 E MAINSTREET STE 150
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARKER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80134-3477
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-841-7900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/05/2016

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
PAMALA
Authorized Official Middle Name:
LEA
Authorized Official Title or Position:
CEO, PRESIDENT
Authorized Official Telephone Number:
918-704-5556

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  CRNA-01442 , 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)





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