Provider Demographics
NPI:1932715737
Name:BLUE WATER ANESTHESIA, LLC
Entity Type:Organization
Organization Name:BLUE WATER ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:CHRISTINA
Authorized Official - Last Name:STUBBS
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:803-238-6913
Mailing Address - Street 1:1310 WESTLOOP PL STE A
Mailing Address - Street 2:#339
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502
Mailing Address - Country:US
Mailing Address - Phone:803-238-6913
Mailing Address - Fax:
Practice Address - Street 1:1823 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-3381
Practice Address - Country:US
Practice Address - Phone:803-238-6913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty