Healthcare Provider Details

I. General information

NPI: 1053603993
Provider Name (Legal Business Name): CLINT B PITCHFORTH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2011
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 E 3RD ST
DELTA CO
81416-2815
US

IV. Provider business mailing address

PO BOX 10100
DELTA CO
81416-0008
US

V. Phone/Fax

Practice location:
  • Phone: 970-874-7681
  • Fax: 970-874-6400
Mailing address:
  • Phone: 970-874-7681
  • Fax: 970-874-6400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA-01147
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number250160
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number100093
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: