Healthcare Provider Details

I. General information

NPI: 1750710778
Provider Name (Legal Business Name): SOUTH LAKE ANESTHESIA SERVICES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2013
Last Update Date: 11/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1099 CITRUS TOWER BLVD
CLERMONT FL
34711-1947
US

IV. Provider business mailing address

1381 CITRUS TOWER BLVD SUITE 4
CLERMONT FL
34711-1957
US

V. Phone/Fax

Practice location:
  • Phone: 352-394-4071
  • Fax:
Mailing address:
  • Phone: 352-243-9114
  • Fax: 352-243-7822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BRIAN CONNOR
Title or Position: ADMINISTRATOR
Credential:
Phone: 352-243-9114