Provider Demographics
NPI:1750710778
Name:SOUTH LAKE ANESTHESIA SERVICES, P.A.
Entity type:Organization
Organization Name:SOUTH LAKE ANESTHESIA SERVICES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-243-9114
Mailing Address - Street 1:1381 CITRUS TOWER BLVD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-1957
Mailing Address - Country:US
Mailing Address - Phone:352-243-9114
Mailing Address - Fax:352-243-7822
Practice Address - Street 1:1099 CITRUS TOWER BLVD
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1947
Practice Address - Country:US
Practice Address - Phone:352-394-4071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45233Medicare PIN