=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487875225
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOVA ANESTHESIA CRNA'S
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1501 MOUNT PLEASANT RD
-----------------------------------------------------
City | VILLANOVA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19085-2112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-386-2366
-----------------------------------------------------
Fax | 570-386-3130
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 428
-----------------------------------------------------
City | LEHIGHTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18235-0428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-386-2366
-----------------------------------------------------
Fax | 570-386-3130
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | KELLY ALEXANDER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 570-386-2366
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------