Healthcare Provider Details

I. General information

NPI: 1073051884
Provider Name (Legal Business Name): SAMUEL TAYLOR CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2017
Last Update Date: 02/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 LOUISIANA BLVD NE SUITE 401
ALBUQUERQUE NM
87110-7022
US

IV. Provider business mailing address

1720 LOUISIANA BLVD NE SUITE 401
ALBUQUERQUE NM
87110-7022
US

V. Phone/Fax

Practice location:
  • Phone: 505-260-4300
  • Fax: 505-260-4371
Mailing address:
  • Phone: 505-260-4300
  • Fax: 505-260-4371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA-01470
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: