Provider Demographics
NPI:1386836997
Name:NODAK ANESTHESIA, INC
Entity Type:Organization
Organization Name:NODAK ANESTHESIA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:J.
Authorized Official - Middle Name:WYNN
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:559-816-5062
Mailing Address - Street 1:PO BOX 264
Mailing Address - Street 2:
Mailing Address - City:LEMOORE
Mailing Address - State:CA
Mailing Address - Zip Code:93245-0264
Mailing Address - Country:US
Mailing Address - Phone:559-813-5062
Mailing Address - Fax:
Practice Address - Street 1:1025 N DOUTY ST
Practice Address - Street 2:CENTRAL VALLEY GEN. HOSPITAL
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-3722
Practice Address - Country:US
Practice Address - Phone:559-587-4344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGRN000140207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGRN000140Medicaid