Basic Information
| Provider Information | |||||||||
| NPI: | 1992028088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SNEDAKER | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6210 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874996210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053266400 | ||||||||
| FaxNumber: | 5053264606 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 W MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 874015630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5056092000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2010 | ||||||||
| LastUpdateDate: | 07/26/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN589897 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 40929051 | 05 | NM | MEDICAID | 1992028088 | 05 | UT | MEDICAID | 67406203 | 05 | CO | MEDICAID | 634505 | 05 | AZ | MEDICAID | NMAAA1458 | 01 | NM | MEDICARE PTAN | OTHER |