Provider Demographics
NPI:1245208859
Name:KLIEWER, GARY D (CRNA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:D
Last Name:KLIEWER
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 1:1441 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2837
Mailing Address - Country:US
Mailing Address - Phone:602-495-4577
Mailing Address - Fax:602-417-3549
Practice Address - Street 1:2400 EDISON ST
Practice Address - Street 2:
Practice Address - City:BRUSH
Practice Address - State:CO
Practice Address - Zip Code:80723-1642
Practice Address - Country:US
Practice Address - Phone:970-842-6200
Practice Address - Fax:970-842-3572
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN70205367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
458608Medicare ID - Type Unspecified
CO07001381Medicare ID - Type Unspecified