Healthcare Provider Details

I. General information

NPI: 1053508564
Provider Name (Legal Business Name): FREMONT ANESTHESIA ASSOCIATE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2007
Last Update Date: 11/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 W SUNSET DR
RIVERTON WY
82501-2274
US

IV. Provider business mailing address

PO BOX 30918
BILLINGS MT
59116-0918
US

V. Phone/Fax

Practice location:
  • Phone: 800-967-1646
  • Fax: 317-567-2191
Mailing address:
  • Phone: 317-567-2180
  • Fax: 317-567-2191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateWY

VIII. Authorized Official

Name: MATTHEW A MULLINIX
Title or Position: MANAGING GROUP MEMBER
Credential: CRNA
Phone: 307-856-4161