Healthcare Provider Details

I. General information

NPI: 1134155443
Provider Name (Legal Business Name): EDWARD S SANSHU CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 E ROOSEVELT AVE
GRANTS NM
87020-2118
US

IV. Provider business mailing address

80007 LOBO CP
GRANTS NM
87020-9646
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-4446
  • Fax:
Mailing address:
  • Phone: 505-287-4446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR23383
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: