Healthcare Provider Details

I. General information

NPI: 1780124081
Provider Name (Legal Business Name): MOCK ANESTHESIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2017
Last Update Date: 03/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 WYOMING BLVD NE
ALBUQUERQUE NM
87112-3855
US

IV. Provider business mailing address

PO BOX 2823
IDAHO FALLS ID
83403-2823
US

V. Phone/Fax

Practice location:
  • Phone: 505-721-7200
  • Fax:
Mailing address:
  • Phone: 208-525-2090
  • Fax: 208-523-8978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN-76102
License Number StateNM

VIII. Authorized Official

Name: MRS. CONNIE L CROFT
Title or Position: BILLING MANAGER
Credential: CPC
Phone: 208-525-2090