Healthcare Provider Details

I. General information

NPI: 1437417748
Provider Name (Legal Business Name): TREVOR R WILLARDSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2012
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 WEST 16TH
PUEBLO CO
81003-2828
US

IV. Provider business mailing address

1218 NORTH MAIN ST.
PUEBLO CO
81003-2828
US

V. Phone/Fax

Practice location:
  • Phone: 719-584-4420
  • Fax:
Mailing address:
  • Phone: 719-543-7877
  • Fax: 719-543-7882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRA100105
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: