Basic Information
| Provider Information | |||||||||
| NPI: | 1457597940 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOGARTY | ||||||||
| FirstName: | AMBER | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TODARA | ||||||||
| OtherFirstName: | AMBER | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 332 W BROADWAY | ||||||||
| Address2: | SUITE 810 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402022130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025830909 | ||||||||
| FaxNumber: | 5025830913 | ||||||||
| Practice Location | |||||||||
| Address1: | 332 W BROADWAY | ||||||||
| Address2: | SUITE 810 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402022130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025830909 | ||||||||
| FaxNumber: | 5025830913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2009 | ||||||||
| LastUpdateDate: | 07/29/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 5918A | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 5918A | 01 | KY | CRNA | OTHER |