Provider Demographics
NPI:1679865372
Name:ESTES VALLEY ANESTHESIA LLC
Entity Type:Organization
Organization Name:ESTES VALLEY ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:970-443-8855
Mailing Address - Street 1:850 NORTH LN
Mailing Address - Street 2:
Mailing Address - City:ESTES PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80517-9629
Mailing Address - Country:US
Mailing Address - Phone:970-443-8855
Mailing Address - Fax:
Practice Address - Street 1:850 NORTH LN
Practice Address - Street 2:
Practice Address - City:ESTES PARK
Practice Address - State:CO
Practice Address - Zip Code:80517-9629
Practice Address - Country:US
Practice Address - Phone:970-443-8855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCRA-2933367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC802029OtherMEDICARE ID FOR MARY BOLGEO
CO17228042Medicaid
COC188438OtherMEDICARE ID FOR JASON GOODWIN
CO52909361Medicaid