Basic Information
| Provider Information | |||||||||
| NPI: | 1548582000 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENESIS ANESTHESIA SERVICES PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 97115 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984970115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535887911 | ||||||||
| FaxNumber: | 2539846774 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 LITTLE MOUNTAIN LN | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982748752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535887911 | ||||||||
| FaxNumber: | 2539846774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2010 | ||||||||
| LastUpdateDate: | 02/24/2010 | ||||||||
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| AuthorizedOfficialLastName: | CESSNA | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2535887911 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN60124881 | WA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | 163W00000X | RN516520L | PA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | 367500000X | 60130625 | WA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | RN60124881 | 01 | WA | REGISTERED NURSE LICENSE | OTHER | 60130625 | 01 | WA | STATE LICENSE | OTHER |