Provider Demographics
NPI:1235230152
Name:MATHAHS, KEITH (CRNA)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:MATHAHS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SHADOW LN
Mailing Address - Street 2:SUITE #165A
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4126
Mailing Address - Country:US
Mailing Address - Phone:702-382-8101
Mailing Address - Fax:702-382-0803
Practice Address - Street 1:700 SHADOW LN
Practice Address - Street 2:SUITE #165A
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4126
Practice Address - Country:US
Practice Address - Phone:702-382-8101
Practice Address - Fax:702-382-0803
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCRNA000226367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVR22212Medicare UPIN
NV37276Medicare ID - Type Unspecified