Basic Information
| Provider Information | |||||||||
| NPI: | 1114519394 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALTUS ANESTHESIA PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 960 RIDGEVIEW DRIVE | ||||||||
| Address2: | STE 140 - 195 | ||||||||
| City: | ALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143907697 | ||||||||
| FaxNumber: | 9724326692 | ||||||||
| Practice Location | |||||||||
| Address1: | 4317 MAIZE DR | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750933233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143907697 | ||||||||
| FaxNumber: | 9724326692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2021 | ||||||||
| LastUpdateDate: | 02/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | MOBARAK | ||||||||
| AuthorizedOfficialFirstName: | REZA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMIN | ||||||||
| AuthorizedOfficialTelephone: | 2143907697 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.