Provider Demographics
NPI:1417249996
Name:WOODLAND PARK ANESTHESIA LLC
Entity Type:Organization
Organization Name:WOODLAND PARK ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LONNIE
Authorized Official - Middle Name:W
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-790-3928
Mailing Address - Street 1:PO BOX 9040
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80866-9040
Mailing Address - Country:US
Mailing Address - Phone:719-900-3960
Mailing Address - Fax:
Practice Address - Street 1:16420 W US HIGHWAY 24
Practice Address - Street 2:
Practice Address - City:WOODLAND PARK
Practice Address - State:CO
Practice Address - Zip Code:80863-8760
Practice Address - Country:US
Practice Address - Phone:719-687-9989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-03
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO09932275Medicaid
COCOAAA0139OtherMEDICARE PTAN