Provider Demographics
NPI:1740275924
Name:CARMEN, LORI (CRNA)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:CARMEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CORDOVA PL
Mailing Address - Street 2:# 712
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-1725
Mailing Address - Country:US
Mailing Address - Phone:505-747-8639
Mailing Address - Fax:
Practice Address - Street 1:1010 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-3456
Practice Address - Country:US
Practice Address - Phone:505-753-7111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR47417367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM430074229OtherRAILROAD MEDICARE INDIVID
NMNM006426OtherBCB NM - INDIVIDUAL
NM17104505Medicaid