Healthcare Provider Details

I. General information

NPI: 1134987019
Provider Name (Legal Business Name): MARIPOSA ANESTHESIA SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2024
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11850 THOMAS MILL DR
GLEN ALLEN VA
23059-4726
US

IV. Provider business mailing address

921 SHERWOOD DR
LAKE BLUFF IL
60044-2203
US

V. Phone/Fax

Practice location:
  • Phone: 800-444-6110
  • Fax:
Mailing address:
  • Phone: 800-444-6110
  • Fax: 224-255-5813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: SARAH F LAZCANO
Title or Position: CRNA
Credential:
Phone: 804-677-5659