Basic Information
Provider Information | |||||||||
NPI: | 1124041884 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REARDON | ||||||||
FirstName: | ECHO | ||||||||
MiddleName: | R. | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FISHER | ||||||||
OtherFirstName: | ECHO | ||||||||
OtherMiddleName: | R. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 355 GILBERT AVE | ||||||||
Address2: |   | ||||||||
City: | EAU CLAIRE | ||||||||
State: | WI | ||||||||
PostalCode: | 547013902 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3098250980 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1200 GRANT BLVD W | ||||||||
Address2: |   | ||||||||
City: | WABASHA | ||||||||
State: | MN | ||||||||
PostalCode: | 559811042 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6515654531 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/25/2006 | ||||||||
LastUpdateDate: | 07/31/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 041285078 | IL | N |   | Nursing Service Providers | Registered Nurse |   | 163W00000X | 28187929A | IN | N |   | Nursing Service Providers | Registered Nurse |   | 367500000X | 209001650 | IL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | 209-001650 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 214881 | 01 | IL | MULTI SPECIALTY GROUP PTAN | OTHER | 50148 | 01 |   | AANA | OTHER |