Provider Demographics
NPI:1508185760
Name:BLACK, LEVI COLTER (CRNA)
Entity Type:Individual
Prefix:
First Name:LEVI
Middle Name:COLTER
Last Name:BLACK
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 1:530B HARKLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4739
Mailing Address - Country:US
Mailing Address - Phone:480-254-1430
Mailing Address - Fax:
Practice Address - Street 1:117 E 19TH ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5151
Practice Address - Country:US
Practice Address - Phone:814-877-2137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-26
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCRNA0680367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ528136Medicaid
AZ1508185760Medicaid
AZ528136Medicaid
AZZ138138Medicare PIN