Basic Information
| Provider Information | |||||||||
| NPI: | 1093165094 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DRIFT AWAY ANESTHESIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 209 S MAIN ST | ||||||||
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| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639015831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736865550 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 JOHN Q HAMMONS DR STE 102 | ||||||||
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| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537171967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736865550 | ||||||||
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| ProviderEnumerationDate: | 06/21/2016 | ||||||||
| LastUpdateDate: | 06/21/2016 | ||||||||
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| AuthorizedOfficialLastName: | CARLSON | ||||||||
| AuthorizedOfficialFirstName: | RENEE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MBR | ||||||||
| AuthorizedOfficialTelephone: | 5736865550 | ||||||||
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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 | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.