Healthcare Provider Details

I. General information

NPI: 1184603201
Provider Name (Legal Business Name): BUENA VISTA ANESTHESIA ASSOCIATES PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 07/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 W 5TH ST
STORM LAKE IA
50588
US

IV. Provider business mailing address

209 S MAIN ST
POPLAR BLUFF MO
63901-5831
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-5550
  • Fax: 573-686-2139
Mailing address:
  • Phone: 573-686-5550
  • Fax: 573-686-5550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number100514
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number148752
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD040615
License Number StateIA

VIII. Authorized Official

Name: MS. STEPHANIE MAXINE KRAUTH
Title or Position: OPERATING MANAGER
Credential: CRNA
Phone: 573-686-5550