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General NPI Number Information
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NPI Number | 1558361089
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Entity Type | Organization
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Legal Business Name | TIERRA ALTA ANESTHESIA
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Dates
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Enumeration Date | 07/27/2005
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 1010 SPRUCE ST
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City | ESPANOLA
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State | NM
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Zip | 87532-3456
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Country | US
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Telephone | 573-686-5550
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Fax |
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Provider Business Mailing Address
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Address Line | 209 S MAIN ST
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City | POPLAR BLUFF
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State | MO
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Zip | 63901-5831
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Country | US
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Telephone | 573-686-5550
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Fax | 573-686-2136
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. PETER HOLTZ
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Credential | CRNA
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Telephone | 573-686-5550
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number |
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License Number State | NM
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