Provider Demographics
NPI:1578916482
Name:FREELANCE ANESTHESIA NEW MEXICO, LLC
Entity Type:Organization
Organization Name:FREELANCE ANESTHESIA NEW MEXICO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PAMALA
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DNAP,CRNA
Authorized Official - Phone:918-704-5556
Mailing Address - Street 1:2681 CRIMSON CLOVER RD SW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-6544
Mailing Address - Country:US
Mailing Address - Phone:918-704-5556
Mailing Address - Fax:
Practice Address - Street 1:805 E HIGH ST
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2448
Practice Address - Country:US
Practice Address - Phone:918-704-5556
Practice Address - Fax:866-550-2242
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FREELANCE ANESTHESIA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0991841367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty