Healthcare Provider Details

I. General information

NPI: 1124265590
Provider Name (Legal Business Name): KRISTOPHER A. BLACK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2009
Last Update Date: 07/08/2021
Certification Date: 07/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 MINNEQUA AVE OR/ANESTHESIOLOGY
PUEBLO CO
81004-3733
US

IV. Provider business mailing address

PO BOX 1155 ATTN AQREVA
BILLINGS MT
59103-1155
US

V. Phone/Fax

Practice location:
  • Phone: 719-557-3824
  • Fax: 719-557-3834
Mailing address:
  • Phone: 719-557-3824
  • Fax: 719-557-3834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number47932
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number121197
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: