MEDICARE: MASON COUNTY ANESTHESIA SERVICES PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician		WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8934002	OTHER	WA	CRIME VICTIM COMP PROGRAM
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	0128180	OTHER	WA	DEPT OF LABOR & INDUSTRY

General Provider Information

NPI Number	:	1003878471
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MASON COUNTY ANESTHESIA SERVICES PLLC

Provider Business Mailing Address
First Line	:	400 E 10TH ST
Second Line	:
City	:	WACONIA
State	:	MN
Zip	:	55387-4552
Country	:	US
Telephone Number	:	952-442-9770
Fax Number	:	952-442-3630

Provider Business Practice Location Address
First Line	:	901 MT VIEW DR
Second Line	:	BLDG 1
City	:	SHELTON
State	:	WA
Zip	:	98584-4401
Country	:	US
Telephone Number	:	360-426-1611
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DEBORAH HARTLEY
Credential	:	CRNA
Telephone Number	:	360-427-3625

Provider Enumeration Date	:	04/03/2006
Last Update Date	:	04/29/2008

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