MEDICARE: JAMES R SUNDET CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	0144	SD
2	367500000X	Certified Registered Nurse Anesthetist	D103511	IA
3	367500000X	Certified Registered Nurse Anesthetist	NA2840	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	145405	OTHER	KS	BCBS KS GROUP 110017
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306810221
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES R SUNDET CRNA

Provider Business Mailing Address
First Line	:	PO BOX 7096
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95267-0096
Country	:	US
Telephone Number	:	209-956-7725
Fax Number	:	209-956-7733

Provider Business Practice Location Address
First Line	:	726 4TH ST
Second Line	:
City	:	MARYSVILLE
State	:	CA
Zip	:	95901-5656
Country	:	US
Telephone Number	:	530-749-4300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/15/2006
Last Update Date	:	06/01/2016

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