Basic Information
| Provider Information | |||||||||
| NPI: | 1649694654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARRETT | ||||||||
| FirstName: | MARIE | ||||||||
| MiddleName: | ALTAGRACE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GARRETT | ||||||||
| OtherFirstName: | MARIE | ||||||||
| OtherMiddleName: | ALTAGRACE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4700 LAS VEGAS BLVD N | ||||||||
| Address2: | |||||||||
| City: | NELLIS AFB | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891916600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026533550 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4700 LAS VEGAS BLVD N | ||||||||
| Address2: | |||||||||
| City: | NELLIS AFB | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026533550 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2014 | ||||||||
| LastUpdateDate: | 05/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | ARNP9270307 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 01 | FL | BCBS | OTHER | PENDING | 05 | FL | MEDICAID |