Basic Information
| Provider Information | |||||||||
| NPI: | 1639346836 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CACTUS VALLEY ANESTHESIA PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 29211 | ||||||||
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| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850389211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022736770 | ||||||||
| FaxNumber: | 6028890483 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 E SHOW LOW LAKE RD | ||||||||
| Address2: | |||||||||
| City: | SHOW LOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859017831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022736770 | ||||||||
| FaxNumber: | 6028890483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2008 | ||||||||
| LastUpdateDate: | 05/15/2008 | ||||||||
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| AuthorizedOfficialLastName: | KYCEY | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 6022736770 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN065393 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.