Provider Demographics
NPI:1821081746
Name:VAZQUEZ, KIM A (CRNA)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:A
Last Name:VAZQUEZ
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:SHANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:2 CATHARINE STREET, P.O. BOX 550
Mailing Address - Street 2:EAST MANHATTAN ANESTHESIA PARTNERS, LLC
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12602
Mailing Address - Country:US
Mailing Address - Phone:866-868-8415
Mailing Address - Fax:845-790-2675
Practice Address - Street 1:310 E 14TH STREET
Practice Address - Street 2:MY EYE & EAR INFIRMARY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003
Practice Address - Country:US
Practice Address - Phone:212-979-4464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY463192367500000X
NY463192-1367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR9A621Medicare PIN