Provider Demographics
NPI:1699218149
Name:TRIDENT ANESTHESIA LLC
Entity Type:Organization
Organization Name:TRIDENT ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:CHAUCER
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:817-727-0985
Mailing Address - Street 1:400 10TH ST E
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-4552
Mailing Address - Country:US
Mailing Address - Phone:682-297-6708
Mailing Address - Fax:952-442-3620
Practice Address - Street 1:2001 COOPER ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2529
Practice Address - Country:US
Practice Address - Phone:682-800-1099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-30
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX802560511367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty