Healthcare Provider Details

I. General information

NPI: 1659099448
Provider Name (Legal Business Name): SIESTA PEDIATRIC ANESTHESIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2022
Last Update Date: 08/17/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8427 LINDRICK LN
BRADENTON FL
34202-4626
US

IV. Provider business mailing address

PO BOX 1
TAMPA FL
33601-0001
US

V. Phone/Fax

Practice location:
  • Phone: 407-319-5000
  • Fax:
Mailing address:
  • Phone: 407-319-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MIRIAM CHAN
Title or Position: OWNER
Credential: MD
Phone: 407-319-5000