Healthcare Provider Details

I. General information

NPI: 1982111456
Provider Name (Legal Business Name): MATEO GENNETTE CRNA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2018
Last Update Date: 01/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 OLIVE DR
BAKERSFIELD CA
93308-4137
US

IV. Provider business mailing address

PO BOX 2029
BAKERSFIELD CA
93303-2029
US

V. Phone/Fax

Practice location:
  • Phone: 661-399-4461
  • Fax: 661-399-7312
Mailing address:
  • Phone: 661-335-7755
  • Fax: 661-335-7766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95000160
License Number StateCA

VIII. Authorized Official

Name: SANDY REED
Title or Position: MANAGER
Credential:
Phone: 661-335-7755