Basic Information
| Provider Information | |||||||||
| NPI: | 1003878471 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MASON COUNTY ANESTHESIA SERVICES PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 E 10TH ST | ||||||||
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| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553874552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524429770 | ||||||||
| FaxNumber: | 9524423630 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 MT VIEW DR | ||||||||
| Address2: | BLDG 1 | ||||||||
| City: | SHELTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985844401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604261611 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 04/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | HARTLEY | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3604273625 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | WA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 8934002 | 01 | WA | CRIME VICTIM COMP PROGRAM | OTHER | 7096241 | 05 | WA | MEDICAID | 0128180 | 01 | WA | DEPT OF LABOR & INDUSTRY | OTHER |