Healthcare Provider Details

I. General information

NPI: 1093165094
Provider Name (Legal Business Name): DRIFT AWAY ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 JOHN Q HAMMONS DR STE 102
MADISON WI
53717-1967
US

IV. Provider business mailing address

209 S MAIN ST
POPLAR BLUFF MO
63901-5831
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-5550
  • Fax:
Mailing address:
  • Phone: 573-686-5550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: RENEE M CARLSON
Title or Position: MBR
Credential: CRNA
Phone: 715-213-7529