Healthcare Provider Details

I. General information

NPI: 1790320307
Provider Name (Legal Business Name): BENTON JAMES LUNT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2019
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W MAPLE ST
FARMINGTON NM
87401-5630
US

IV. Provider business mailing address

PO BOX 6210
FARMINGTON NM
87499-6210
US

V. Phone/Fax

Practice location:
  • Phone: 505-609-6098
  • Fax: 505-609-2259
Mailing address:
  • Phone: 505-609-2258
  • Fax: 505-609-2259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number127832
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: