Basic Information
| Provider Information | |||||||||
| NPI: | 1548364888 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANESTHESIA ASSOCIATES OF LARAMIE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1562 | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834031562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085252090 | ||||||||
| FaxNumber: | 2085238978 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 N 30TH ST | ||||||||
| Address2: | |||||||||
| City: | LARAMIE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820725140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077422141 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2006 | ||||||||
| LastUpdateDate: | 10/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | CRECCA | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3077609897 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 114752800 | 05 | WY | MEDICAID |