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NPI Code Detail

MEDICARE: TIERRA ALTA ANESTHESIA

MEDICARE: TIERRA ALTA ANESTHESIA
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
1367500000XCertified Registered Nurse AnesthetistNM

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1NM006869OTHERNMBCBSNM GROUP

General Provider Information

NPI Number : 1558361089
Entity Type Code : Organization
Provider Name (Legal Business Name) : TIERRA ALTA ANESTHESIA
Provider Business Mailing Address
First Line : 209 S MAIN ST
Second Line :
City : POPLAR BLUFF
State : MO
Zip : 63901-5831
Country : US
Telephone Number : 573-686-5550
Fax Number : 573-686-2136
Provider Business Practice Location Address
First Line : 1010 SPRUCE ST
Second Line :
City : ESPANOLA
State : NM
Zip : 87532-3456
Country : US
Telephone Number : 573-686-5550
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : MR. PETER HOLTZ
Credential : CRNA
Telephone Number : 573-686-5550
Provider Enumeration Date : 07/27/2005
Last Update Date : 07/21/2022

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Directions to “TIERRA ALTA ANESTHESIA ” Practice Location

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