Basic Information
| Provider Information | |||||||||
| NPI: | 1053603993 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PITCHFORTH | ||||||||
| FirstName: | CLINT | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10100 | ||||||||
| Address2: | |||||||||
| City: | DELTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814160008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708747681 | ||||||||
| FaxNumber: | 9708746400 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 E 3RD ST | ||||||||
| Address2: | |||||||||
| City: | DELTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814162815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708747681 | ||||||||
| FaxNumber: | 9708746400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2011 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | CRNA-01147 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 250160 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 100093 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 634497 | 05 | AZ | MEDICAID | 1053603993 | 05 | UT | MEDICAID | 25670875 | 05 | CO | MEDICAID | 69837252 | 05 | NM | MEDICAID | NMAAA1472 | 01 | NM | MEDICARE PTAN | OTHER |