Provider Demographics
NPI:1821254566
Name:WESTLAKE NURSE ANESTHESIA GROUP
Entity Type:Organization
Organization Name:WESTLAKE NURSE ANESTHESIA GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:REX
Authorized Official - Middle Name:A
Authorized Official - Last Name:TUNGATE
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:270-384-4753
Mailing Address - Street 1:901 WESTLAKE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:KY
Mailing Address - Zip Code:42728-1123
Mailing Address - Country:US
Mailing Address - Phone:270-384-4753
Mailing Address - Fax:270-385-9123
Practice Address - Street 1:901 WESTLAKE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:KY
Practice Address - Zip Code:42728-1123
Practice Address - Country:US
Practice Address - Phone:270-384-4753
Practice Address - Fax:270-385-9123
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADAIR COUNTY HOSPITAL DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-01
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1000001367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7490035800Medicaid