Healthcare Provider Details

I. General information

NPI: 1922018787
Provider Name (Legal Business Name): PHILIPPE BONNEAU CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 12/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 SAINT MICHAELS DR
SANTA FE NM
87505-7601
US

IV. Provider business mailing address

455 SAINT MICHAELS DR CARLA GOMEZ, CREDENTIALING COORDINTOR
SANTA FE NM
87505-7601
US

V. Phone/Fax

Practice location:
  • Phone: 505-820-5554
  • Fax: 505-820-5440
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA00322
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: