Provider Demographics
NPI:1922577535
Name:MARBLE MOUNTAIN ANESTHESIA, INC., A PROFESSIONAL NURSING CORPORATION
Entity Type:Organization
Organization Name:MARBLE MOUNTAIN ANESTHESIA, INC., A PROFESSIONAL NURSING CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CFO/SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:530-240-5115
Mailing Address - Street 1:112 SERPA LN
Mailing Address - Street 2:
Mailing Address - City:FORT JONES
Mailing Address - State:CA
Mailing Address - Zip Code:96032-9734
Mailing Address - Country:US
Mailing Address - Phone:530-240-5115
Mailing Address - Fax:530-841-6286
Practice Address - Street 1:444 BRUCE ST
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-3450
Practice Address - Country:US
Practice Address - Phone:530-841-6283
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty