Provider Demographics
NPI:1467167221
Name:SUNDANCE ANESTHESIA LLC
Entity Type:Organization
Organization Name:SUNDANCE ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:509-926-1770
Mailing Address - Street 1:6002 S YALE RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-1744
Mailing Address - Country:US
Mailing Address - Phone:509-990-5997
Mailing Address - Fax:509-228-9542
Practice Address - Street 1:6002 S YALE RD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-1744
Practice Address - Country:US
Practice Address - Phone:509-990-5997
Practice Address - Fax:509-228-9542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP60097099OtherWASHINGTON STATE DEPARTMENT OF HEALTH