Provider Demographics
NPI:1275019820
Name:MOUNTAIN VALLEY ANESTHESIA
Entity Type:Organization
Organization Name:MOUNTAIN VALLEY ANESTHESIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:DUPUY
Authorized Official - Last Name:HERRERO
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:864-915-1878
Mailing Address - Street 1:PO BOX 1241
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:CO
Mailing Address - Zip Code:80428-1241
Mailing Address - Country:US
Mailing Address - Phone:864-915-1878
Mailing Address - Fax:
Practice Address - Street 1:750 HOSPITAL LOOP
Practice Address - Street 2:
Practice Address - City:CRAIG
Practice Address - State:CO
Practice Address - Zip Code:81625-8750
Practice Address - Country:US
Practice Address - Phone:918-850-5607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COC-APN.0000708-C-CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty