Basic Information
| Provider Information | |||||||||
| NPI: | 1437139193 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNCOMPAHGRE ANESTHESIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 530 | ||||||||
| Address2: | |||||||||
| City: | OLATHE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814250530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703238703 | ||||||||
| FaxNumber: | 9702498421 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 S 3RD ST | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814014212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703238703 | ||||||||
| FaxNumber: | 9702498421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DWYER | ||||||||
| AuthorizedOfficialFirstName: | TANYA | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9703238703 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN, CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 110448 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 24921815 | 05 | CO | MEDICAID |