Provider Demographics
NPI:1740900265
Name:FOUNTAIN ANESTHESIA, LLC
Entity type:Organization
Organization Name:FOUNTAIN ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOUNTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:480-414-1295
Mailing Address - Street 1:5000 E PALOMINO LN UNIT 21
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-7444
Mailing Address - Country:US
Mailing Address - Phone:480-414-1295
Mailing Address - Fax:
Practice Address - Street 1:5000 E PALOMINO LN UNIT 21
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-7444
Practice Address - Country:US
Practice Address - Phone:480-414-1295
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-02
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty