Basic Information
| Provider Information | |||||||||
| NPI: | 1215243910 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN PEDRO ANESTHESIA PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 29211 | ||||||||
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| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850389211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022736770 | ||||||||
| FaxNumber: | 6028890483 | ||||||||
| Practice Location | |||||||||
| Address1: | 494 N CARONDELET DR | ||||||||
| Address2: | |||||||||
| City: | NOGALES | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856212453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207611603 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2010 | ||||||||
| LastUpdateDate: | 09/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | KING | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6022736770 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.