Provider Demographics
NPI:1053321729
Name:MT NEBO ANESTHESIA ASSOCIATES LLC
Entity Type:Organization
Organization Name:MT NEBO ANESTHESIA ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEVON
Authorized Official - Middle Name:D
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:800-748-4868
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3810
Mailing Address - Country:US
Mailing Address - Phone:800-748-4868
Mailing Address - Fax:770-701-6674
Practice Address - Street 1:48 W 1500 N
Practice Address - Street 2:
Practice Address - City:NEPHI
Practice Address - State:UT
Practice Address - Zip Code:84648-8900
Practice Address - Country:US
Practice Address - Phone:435-623-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000058139Medicare ID - Type Unspecified