Provider Demographics
NPI:1164882346
Name:SWANEMYR, TIA GABRIELLE (CST/CSFA)
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:GABRIELLE
Last Name:SWANEMYR
Suffix:
Gender:F
Credentials:CST/CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1848 COUNTY ROAD 316
Mailing Address - Street 2:
Mailing Address - City:IGNACIO
Mailing Address - State:CO
Mailing Address - Zip Code:81137-9707
Mailing Address - Country:US
Mailing Address - Phone:970-779-8419
Mailing Address - Fax:
Practice Address - Street 1:1848 COUNTY ROAD 316
Practice Address - Street 2:
Practice Address - City:IGNACIO
Practice Address - State:CO
Practice Address - Zip Code:81137-9707
Practice Address - Country:US
Practice Address - Phone:970-779-8419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-01
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant