Basic Information
| Provider Information | |||||||||
| NPI: | 1437417748 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLARDSON | ||||||||
| FirstName: | TREVOR | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1218 NORTH MAIN ST. | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810032828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195437877 | ||||||||
| FaxNumber: | 7195437882 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 WEST 16TH | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810032828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195844420 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2012 | ||||||||
| LastUpdateDate: | 07/07/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | CRA100105 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.