Basic Information
Provider Information | |||||||||
NPI: | 1851807531 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LJM ANESTHESIA PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5959 GATEWAY BLVD W STE 120 | ||||||||
Address2: |   | ||||||||
City: | EL PASO | ||||||||
State: | TX | ||||||||
PostalCode: | 799253315 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9157791716 | ||||||||
FaxNumber: | 9157791754 | ||||||||
Practice Location | |||||||||
Address1: | 1300 MURCHISON DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | EL PASO | ||||||||
State: | TX | ||||||||
PostalCode: | 799024838 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9152257600 | ||||||||
FaxNumber: | 9152257600 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/18/2017 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MORENO | ||||||||
AuthorizedOfficialFirstName: | LISA | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/ PROVIDER | ||||||||
AuthorizedOfficialTelephone: | 7273763065 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
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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 |   |
No ID Information.