Healthcare Provider Details

I. General information

NPI: 1508185760
Provider Name (Legal Business Name): LEVI COLTER BLACK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2010
Last Update Date: 07/05/2021
Certification Date: 07/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 E 19TH ST
ROSWELL NM
88201-5151
US

IV. Provider business mailing address

530B HARKLE RD STE 100
SANTA FE NM
87505-4739
US

V. Phone/Fax

Practice location:
  • Phone: 814-877-2137
  • Fax:
Mailing address:
  • Phone: 480-254-1430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA0680
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: