Healthcare Provider Details

I. General information

NPI: 1104083344
Provider Name (Legal Business Name): AGNOLETTO ANESTHESIA , INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2008
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W BEAVER CREEK BLVD
AVON CO
81620
US

IV. Provider business mailing address

PO BOX 2994
EDWARDS CO
81632-2994
US

V. Phone/Fax

Practice location:
  • Phone: 303-422-9438
  • Fax: 303-422-9474
Mailing address:
  • Phone: 303-422-9438
  • Fax: 303-422-9474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95481
License Number StateCO

VIII. Authorized Official

Name: SALLY K AGNOLETTO
Title or Position: PRESIDENT
Credential: CRNA
Phone: 303-422-9438