Provider Demographics
NPI:1073814513
Name:MOUNTAIN ANESTHESIA, LLC
Entity Type:Organization
Organization Name:MOUNTAIN ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PERSINGER
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:304-542-3927
Mailing Address - Street 1:PO BOX 631
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-0631
Mailing Address - Country:US
Mailing Address - Phone:304-731-2313
Mailing Address - Fax:304-647-4570
Practice Address - Street 1:2830 DAVIS STURT ROAD
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901
Practice Address - Country:US
Practice Address - Phone:304-731-2313
Practice Address - Fax:304-647-4570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2245-8943367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty