Healthcare Provider Details

I. General information

NPI: 1821081746
Provider Name (Legal Business Name): KIM A VAZQUEZ CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIM SHANNON CRNA

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 12/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 E 14TH STREET MY EYE & EAR INFIRMARY
NEW YORK NY
10003
US

IV. Provider business mailing address

2 CATHARINE STREET, P.O. BOX 550 EAST MANHATTAN ANESTHESIA PARTNERS, LLC
POUGHKEEPSIE NY
12602
US

V. Phone/Fax

Practice location:
  • Phone: 212-979-4464
  • Fax:
Mailing address:
  • Phone: 866-868-8415
  • Fax: 845-790-2675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number463192
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number463192-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: