Basic Information
Provider Information | |||||||||
NPI: | 1053759084 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CABRAL | ||||||||
FirstName: | LATASHA | ||||||||
MiddleName: | M. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HEAPE | ||||||||
OtherFirstName: | LATASHA | ||||||||
OtherMiddleName: | M. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CRNA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3001 BROADMOOR BLVD NE | ||||||||
Address2: |   | ||||||||
City: | RIO RANCHO | ||||||||
State: | NM | ||||||||
PostalCode: | 871442100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5059947000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 580 COURT ST | ||||||||
Address2: |   | ||||||||
City: | KEENE | ||||||||
State: | NH | ||||||||
PostalCode: | 034311718 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6033545454 | ||||||||
FaxNumber: | 6033546535 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/12/2013 | ||||||||
LastUpdateDate: | 10/25/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 067601-23 | NH | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | 61083 | NM | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
No ID Information.