Healthcare Provider Details

I. General information

NPI: 1245208859
Provider Name (Legal Business Name): GARY D KLIEWER C.R.N.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 EDISON ST
BRUSH CO
80723-1642
US

IV. Provider business mailing address

1441 N 12TH ST
PHOENIX AZ
85006-2837
US

V. Phone/Fax

Practice location:
  • Phone: 970-842-6200
  • Fax: 970-842-3572
Mailing address:
  • Phone: 602-495-4577
  • Fax: 602-417-3549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN70205
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: