Basic Information
Provider Information | |||||||||
NPI: | 1396778924 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TULARE ANESTHESIA ASSOCIATES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1187 N WILLOW AVE | ||||||||
Address2: | STE 103, PMB#300 | ||||||||
City: | CLOVIS | ||||||||
State: | CA | ||||||||
PostalCode: | 936114411 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5593247300 | ||||||||
FaxNumber: | 5593247350 | ||||||||
Practice Location | |||||||||
Address1: | 869 N CHERRY ST | ||||||||
Address2: |   | ||||||||
City: | TULARE | ||||||||
State: | CA | ||||||||
PostalCode: | 932742207 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5596880821 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/08/2006 | ||||||||
LastUpdateDate: | 09/15/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JIMENEZ | ||||||||
AuthorizedOfficialFirstName: | ERNESTO | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5599053231 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A37394 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | GR0104690 | 05 | CA |   | MEDICAID | 050036290 | 01 | CA | OTHER | OTHER |