Basic Information
Provider Information | |||||||||
NPI: | 1093979643 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MANJARRES | ||||||||
FirstName: | CHRISTOPHER | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4700 LAS VEGAS BLVD N | ||||||||
Address2: | BLDG 1300 | ||||||||
City: | NELLIS AFB | ||||||||
State: | NV | ||||||||
PostalCode: | 891916600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7026533550 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4700 LAS VEGAS BLVD N | ||||||||
Address2: | BLDG 1300 | ||||||||
City: | NELLIS AFB | ||||||||
State: | NV | ||||||||
PostalCode: | 891916600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7026533550 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2008 | ||||||||
LastUpdateDate: | 03/05/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | CRNA000469 | NV | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | CRNA1014 | AZ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 163WF0300X | RN113754 | AZ | N |   | Nursing Service Providers | Registered Nurse | Flight |
No ID Information.