Healthcare Provider Details

I. General information

NPI: 1063658961
Provider Name (Legal Business Name): PREMIER ANESTHESIA OF NEW YORK, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2008
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2233 STATE ROUTE 86
SARANAC LAKE NY
12983-5644
US

IV. Provider business mailing address

2655 NORTHWINDS PKWY
ALPHARETTA GA
30009-2280
US

V. Phone/Fax

Practice location:
  • Phone: 770-643-5501
  • Fax: 404-941-1304
Mailing address:
  • Phone: 770-643-5501
  • Fax: 404-941-1304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number State

VIII. Authorized Official

Name: RANDY WALKER
Title or Position: VICE PRESIDENT
Credential:
Phone: 678-690-7812