Provider Demographics
NPI:1053508564
Name:FREMONT ANESTHESIA ASSOCIATE, PLLC
Entity Type:Organization
Organization Name:FREMONT ANESTHESIA ASSOCIATE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING GROUP MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:A
Authorized Official - Last Name:MULLINIX
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:307-856-4161
Mailing Address - Street 1:PO BOX 30918
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59116-0918
Mailing Address - Country:US
Mailing Address - Phone:317-567-2180
Mailing Address - Fax:317-567-2191
Practice Address - Street 1:2100 W SUNSET DR
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-2274
Practice Address - Country:US
Practice Address - Phone:800-967-1646
Practice Address - Fax:317-567-2191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY207L00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYDG4268OtherRAILROAD MEDICARE
WY1053508564Medicaid
WY06208001OtherBCBS
WY1053508564Medicaid