Basic Information
Provider Information | |||||||||
NPI: | 1841371937 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SUTTER CREEK OB ANESTHESIA SERVICES, A PROFESSIONAL NURSING CORPORATIO | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SUTTER CREEK OB ANESTHESIA SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 966 | ||||||||
Address2: |   | ||||||||
City: | SUTTER CREEK | ||||||||
State: | CA | ||||||||
PostalCode: | 956850966 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8882700340 | ||||||||
FaxNumber: | 8882700331 | ||||||||
Practice Location | |||||||||
Address1: | 7500 TIMBERLAKE WAY | ||||||||
Address2: | METHODIST HOSPITAL | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 95823 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9164233000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/17/2006 | ||||||||
LastUpdateDate: | 01/25/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCCULLEY | ||||||||
AuthorizedOfficialFirstName: | PATRICK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 8882700340 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | ZZZ05546Z | 01 | CA | BLUE SHIELD | OTHER | GRN000080 | 05 | CA |   | MEDICAID |