=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588856116
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARS VANETTEN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2007
-----------------------------------------------------
Last Update Date | 11/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9 JUDYS DREAM LN
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81005-8703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-242-5811
-----------------------------------------------------
Fax | 719-212-2009
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9 JUDYS DREAM LN
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81005-8703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-242-5811
-----------------------------------------------------
Fax | 719-212-2009
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number | 46518
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 46518
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------