Healthcare Provider Details

I. General information

NPI: 1649416124
Provider Name (Legal Business Name): ERIC JOSEPH WEED CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2009
Last Update Date: 06/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 BLANCA AVE
ALAMOSA CO
81101-2340
US

IV. Provider business mailing address

106 BLANCA AVE
ALAMOSA CO
81101-2340
US

V. Phone/Fax

Practice location:
  • Phone: 719-589-2511
  • Fax: 719-587-1372
Mailing address:
  • Phone: 719-589-2511
  • Fax: 719-587-1372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN702032
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRA-15002
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: