Healthcare Provider Details

I. General information

NPI: 1861004715
Provider Name (Legal Business Name): FOLSOM ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 SPRUCE ST
ESPANOLA NM
87532-2746
US

IV. Provider business mailing address

PO BOX 69323
BALTIMORE MD
21264-9323
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-7111
  • Fax: 505-753-4438
Mailing address:
  • Phone: 941-360-1566
  • Fax: 941-358-9818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: KURT ZUMWALT
Title or Position: CEO
Credential:
Phone: 941-360-1566