Provider Demographics
NPI:1083801815
Name:GRAND MESA ANESTHESIA ASSOC, INC
Entity Type:Organization
Organization Name:GRAND MESA ANESTHESIA ASSOC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERALD
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:970-856-6519
Mailing Address - Street 1:PO BOX 791
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:CO
Mailing Address - Zip Code:81416
Mailing Address - Country:US
Mailing Address - Phone:970-856-6519
Mailing Address - Fax:970-856-6546
Practice Address - Street 1:1501 E 3RD STREET
Practice Address - Street 2:DELTA COUNTY MEMORIAL HOSPITAL
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-2815
Practice Address - Country:US
Practice Address - Phone:970-874-7681
Practice Address - Fax:970-874-2227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO75028367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCN7606Medicare PIN