Basic Information
Provider Information | |||||||||
NPI: | 1750561650 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOMBARDIER | ||||||||
FirstName: | ANNE | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MOECKLY | ||||||||
OtherFirstName: | ANNE | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1218 N MAIN ST | ||||||||
Address2: |   | ||||||||
City: | PUEBLO | ||||||||
State: | CO | ||||||||
PostalCode: | 810032828 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195437877 | ||||||||
FaxNumber: | 7195437882 | ||||||||
Practice Location | |||||||||
Address1: | 400 W 16TH ST | ||||||||
Address2: |   | ||||||||
City: | PUEBLO | ||||||||
State: | CO | ||||||||
PostalCode: | 810032745 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195844420 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/07/2007 | ||||||||
LastUpdateDate: | 04/08/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 183804 | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
No ID Information.