Healthcare Provider Details

I. General information

NPI: 1558349977
Provider Name (Legal Business Name): VINCENT W SAGENDORF CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 02/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 SANTA ROSA ST STE. 201
SAN LUIS OBISPO CA
93405-5825
US

IV. Provider business mailing address

PO BOX 4659
SAN LUIS OBISPO CA
93403-4659
US

V. Phone/Fax

Practice location:
  • Phone: 805-544-7246
  • Fax: 805-782-8097
Mailing address:
  • Phone: 805-786-4878
  • Fax: 805-597-8354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberCRNA225
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA000317
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: