Healthcare Provider Details

I. General information

NPI: 1093758831
Provider Name (Legal Business Name): FOUR CORNERS ANESTHESIA, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 08/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 E 30TH ST BLDG A
FARMINGTON NM
87401-8991
US

IV. Provider business mailing address

1515 E 20TH ST SUITE A
FARMINGTON NM
87401-9039
US

V. Phone/Fax

Practice location:
  • Phone: 505-326-6400
  • Fax: 505-326-4606
Mailing address:
  • Phone: 505-326-6400
  • Fax: 505-326-4606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: VERONICA MARTINEZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 505-326-6400