Basic Information
Provider Information | |||||||||
NPI: | 1235541848 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROFESSIONAL ANESTHESIA SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 908 | ||||||||
Address2: |   | ||||||||
City: | BOUNTIFUL | ||||||||
State: | UT | ||||||||
PostalCode: | 840110908 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8012962113 | ||||||||
FaxNumber: | 8012961715 | ||||||||
Practice Location | |||||||||
Address1: | 1600 W ANTELOPE DR | ||||||||
Address2: |   | ||||||||
City: | LAYTON | ||||||||
State: | UT | ||||||||
PostalCode: | 840411142 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8017747020 | ||||||||
FaxNumber: | 8014515136 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/30/2014 | ||||||||
LastUpdateDate: | 05/22/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LINFORD | ||||||||
AuthorizedOfficialFirstName: | ERIC | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8014515136 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CRNA | ||||||||
NPICertificationDate: |   |
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 |   |
ID Information
ID | Type | State | Issuer | Description | 1235541848 | 05 | UT |   | MEDICAID |