Provider Demographics
NPI:1093165094
Name:DRIFT AWAY ANESTHESIA LLC
Entity Type:Organization
Organization Name:DRIFT AWAY ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MBR
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:M
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:573-686-5550
Mailing Address - Street 1:209 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-5831
Mailing Address - Country:US
Mailing Address - Phone:573-686-5550
Mailing Address - Fax:
Practice Address - Street 1:1200 JOHN Q HAMMONS DR STE 102
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-1967
Practice Address - Country:US
Practice Address - Phone:573-686-5550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty