Healthcare Provider Details

I. General information

NPI: 1144748906
Provider Name (Legal Business Name): MOUNTAIN WEST ANESTHESIA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2017
Last Update Date: 09/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20940 N TATUM BLVD STE 100
PHOENIX AZ
85050-7259
US

IV. Provider business mailing address

6728 E GRANDVIEW DR
SCOTTSDALE AZ
85254-5668
US

V. Phone/Fax

Practice location:
  • Phone: 480-502-4000
  • Fax:
Mailing address:
  • Phone: 480-545-2610
  • Fax: 480-545-2673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA0763
License Number StateAZ

VIII. Authorized Official

Name: SORINA KING
Title or Position: BILLING MANAGER
Credential:
Phone: 480-545-2610