Basic Information
| Provider Information | |||||||||
| NPI: | 1093758831 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOUR CORNERS ANESTHESIA, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 E 20TH ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874019039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053266400 | ||||||||
| FaxNumber: | 5053264606 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 E 30TH ST BLDG A | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874018991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053266400 | ||||||||
| FaxNumber: | 5053264606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 08/07/2012 | ||||||||
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| AuthorizedOfficialLastName: | MARTINEZ | ||||||||
| AuthorizedOfficialFirstName: | VERONICA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5053266400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 94002615 | 05 | CO | MEDICAID | F8188 | 05 | NM | MEDICAID | NM07078 | 01 | NM | BCBS | OTHER | 128521 | 05 | AZ | MEDICAID |