Healthcare Provider Details

I. General information

NPI: 1053382929
Provider Name (Legal Business Name): FOUR STATES ANESTHESIA SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 05/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 WEST 32ND STREET SUITE #201
JOPLIN MO
64804
US

IV. Provider business mailing address

PO BOX 388
NEWTON KS
67114-0388
US

V. Phone/Fax

Practice location:
  • Phone: 417-206-7900
  • Fax:
Mailing address:
  • Phone: 316-281-3700
  • Fax: 316-282-4322

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: TERRI SUSANN TRACY
Title or Position: MEMBER
Credential: CRNA
Phone: 417-206-7900